Integrated Care Coach

About the Role

The Care Coach provides proactive, patient-centered care coordination and social needs support for the highest-risk top 5% of patient membership. You will serve as the primary contact for patients, focusing on care coordination, adherence coaching, healthcare navigation, transitions of care, and reinforcing care plans. This role reports to a Care Integration Team Manager within the CenterWell and Conviva Primary Care organization.

This role includes a $2,500 sign-on bonus for new associates, payable after 90 days of employment.

Responsibilities

• Clinical Screening & Escalation: Conduct structured patient interviews and collect health-related information (e.g., medication regimen, 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.
• Must reside in the designated market area.
• Valid state driver’s license and personal vehicle liability insurance (minimum $25,000 bodily injury per person/$25,000 bodily injury per event/$10,000 for property damage or state-mandated minimums).

Preferred Qualifications

• Active unrestricted LPN/LVN license or MA certification.
• Licensed or unlicensed medical professional with equivalent foreign Registered Nurse (RN) or Physician license.
• Bilingual in English, Spanish, and/or Creole (market-dependent).
• 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.

Schedule

• Monday–Friday, 8:00 AM–5:00 PM.
• Overtime may be required.
• Scheduled weekly hours: 40.

Pay

The pay range for this role is $53,700 - $72,600 per year, based on geographic location and individual qualifications such as skills, knowledge, experience, education, and certifications. This role is eligible for a bonus incentive plan based on company and/or individual performance.

Benefits

Humana offers competitive benefits designed to support whole-person well-being, including:

• Medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Paid time off (including paid holidays, parental leave, and caregiver leave).
• Short-term and long-term disability.
• Life insurance.

About Us

About Conviva Senior Primary Care: Conviva Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, and minor injury treatment. As part of Humana’s Primary Care Organization, Conviva’s value-based approach ensures patients receive the best care at the lowest cost while addressing social, emotional, behavioral, and financial needs.

About CenterWell, a Humana company: CenterWell is a leading healthcare services business focused on creating integrated, patient-centered experiences. As the largest provider of senior-focused primary care, a leading provider of home healthcare, and a key player in integrated home delivery, specialty, hospice, and retail pharmacy, CenterWell prioritizes whole health and personalized care.