Integrated Care Coach

Become a part of our caring community. The Care Coach provides proactive, patient-centered care coordination and social needs support for the highest-risk top 5% of patient membership.

About the role

You will serve as the primary contact for patients, focusing on care coordination, adherence coaching, healthcare navigation, transitions of care, and reinforcing care plans. You will report to a Care Integration Team Manager within the CenterWell and Conviva Primary Care organization.

This role has a mobile presence, involving travel to patients’ homes, healthcare facilities, community-based settings, and assigned clinics. Workstyle is a combination of clinic-based and field work (expect an average of 2 days per week in-center and 2 days per week in-home).

Location: Must reside in designated market area.
Hours: Monday–Friday, 8:00 AM–5:00 PM; overtime may be required.

Responsibilities

• Clinical Screening & Escalation: Conduct structured patient interviews and collect health-related information (e.g., medication regimen and barriers to adherence, social barriers, functional status). Document and share findings with providers.
• Outreach and Home Visits: Perform home visits to observe living conditions, identify safety concerns, and review environmental or social factors impacting engagement.
• Social Needs Support: Identify barriers to care, address immediate social stressors, and connect patients with appropriate community-based resources.
• Chronic Disease Education: Deliver culturally appropriate education using approved materials to reinforce provider and pharmacist recommendations for chronic disease management.
• Care Coordination: Serve as a liaison between patients, primary care, specialists, pharmacies, home health, and community providers. Support care transitions, coordinate follow-up, and facilitate communication across care settings to close care gaps. Partner closely with the primary care provider to create care plans and priority action items.
• Post-Hospital and Emergency Department Follow-Up: Conduct timely follow-up after hospitalizations and emergency department visits to support safe transitions. Review discharge instructions, schedule/confirm follow-up appointments, verify patient-reported medications, and escalate discrepancies to providers.
• Community Engagement: Encourage and support patient connection to community-based programs that reinforce health goals, including initial engagement when appropriate.
• Cultural Competence: Deliver patient-centered, culturally sensitive care that respects patients’ beliefs, preferences, and social context.
• Develop a holistic understanding of patient needs via a 5Ms framework (What Matters Most, Mind (Mentation), Mobility, Medications, Multi-complexity) and identify barriers impacting health outcomes.
• Prepare, participate, and discuss patients during High-Risk Rounds.

Requirements

• Healthcare professional with 3+ years of Ambulatory, Primary Care, or Senior-Care experience with direct patient care.
• Ability to discuss chronic conditions and reinforce medication instructions.
• Comfortability to regularly conduct home visits and community-based outreach.
• Demonstrated experience in patient education, care coordination, and social support of high-risk or geriatric populations.

Qualifications

• Active Unrestricted LPN/LVN license or MA Certification.
• Licensed or Unlicensed Medical professional with equivalent foreign Registered Nurse (RN) or Physician license.
• Market Dependent: Bilingual in English, Spanish, and/or Creole with the ability to read/write/speak in both languages.
• Experience in care coordination, case management, population health, and/or value-based care models.
• Experience conducting post-hospital/ED follow-up with appropriate escalation.
• Familiarity with Medicaid, Long-term Care, and HCBS programs.
• Experience working with seniors and medically complex populations.
• Prior home visit experience and knowledge of field safety practices.

Benefits

• Health benefits effective day 1.
• Paid time off, holidays, volunteer time, and jury duty pay.
• Recognition pay.
• 401(k) retirement savings plan with employer match.
• Tuition assistance.
• Scholarships for eligible dependents.
• Parental and caregiver leave.
• Employee charity matching program.
• Network Resource Groups (NRGs).
• Career development opportunities.

Pay

The pay range reflects a good faith estimate of starting base pay for full-time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location, and individual pay will vary based on demonstrated job-related skills, knowledge, experience, education, and certifications.

$59,100 - $79,900 per year. This job is eligible for a bonus incentive plan based on company and/or individual performance.

About Us

About CenterWell Senior Primary Care: CenterWell Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment, and more. Our unique care model focuses on personalized experiences, taking time to listen, learn, and address the factors that impact patient well-being. Our integrated care teams, which include physicians, nurses, behavioral health specialists, and more, spend up to 50 percent more time with patients, providing compassionate, personalized care that brings better health outcomes. We go beyond physical health by also addressing other factors that can impact a patient’s well-being.

About CenterWell, a Humana company: CenterWell is a leading healthcare services business focused on creating integrated and differentiated experiences that put our patients at the center of everything we do. The result is high-quality healthcare that is accessible, comprehensive, and, most of all, personalized. As the largest provider of senior-focused primary care, a leading provider of home healthcare, and a leading integrated home delivery, specialty, hospice, and retail pharmacy, CenterWell is focused on whole health and addressing the physical, emotional, and social wellness of our patients. CenterWell is part of Humana Inc. (NYSE: HUM). Learn more about what we offer at CenterWell.com.