Integrated Care Coach

Become a part of our caring community and help us put health first

The Care Coach provides proactive, patient centered care coordination and social needs support for the highest risk top 5% patient membership. You will serve as the primary contact for patients and focuses 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 Center Well and Conviva Primary Care organization.

This position requires independent patient outreach (weekly), culturally responsive patient activation, patient advocacy, and coordination with healthcare providers and community partners. You will support patients in navigating complex social and clinical systems, prepares them for provider visits, reinforces care plans in partnership with the patient’s PCP and interdisciplinary team members (including the Integrated Clinical Pharmacist and the Integrated Social Worker), and ensures timely follow-up across care settings, including after hospitalization and emergency department encounters.

The Care Coach coordinates care across health and social service systems, serving as patient advocates and clinical supports, including but not limited to:

• 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 upscale 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 5
  
  Ms framework (What M atters Most, M ind (Mentation), M obility, M edications, M ulti-complexity) and identify barriers impacting health outcomes.

• Prepare, participate and discuss patients during High‑Risk Rounds

• 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

• 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…