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% patient membership. You serve as the primary contact for patients, focusing on care coordination, adherence coaching, healthcare navigation, transitions of care, and reinforcement of care plans. You report to a Care Integration Team Manager within the Center Well and Conviva Primary Care organization.

• Clinical Screening & Escalation:
  Conduct structured patient interviews, collect health‑related information (medication regimen, barriers to adherence, social barriers, functional status), and document findings for providers.
• Outreach and Home Visits:
  Perform home visits to assess living conditions, identify safety concerns, and review environmental or social factors affecting engagement.
• Social Needs Support:
  Identify barriers to care, address immediate social stressors, and connect patients with 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 among patients, primary care, specialists, pharmacies, home health, and community providers; support transitions, coordinate follow‑up, and facilitate communication across settings.
• Post‑Hospital and ED Follow‑Up:
  Conduct timely follow‑up after hospital or emergency department visits to support safe transitions, review discharge instructions, schedule appointments, verify medications, and report discrepancies to providers.
• Community Engagement:
  Encourage and support patient connection to community programs that reinforce health goals, including initial engagement when appropriate.
• Cultural Competence:
  Deliver patient‑centered, culturally sensitive care respecting beliefs, preferences, and social context.
• Holistic Assessment:
  Use a 5
  
  Ms framework (What Matters Most, Mind, Mobility, Medications, Multi‑complexity) to identify barriers impacting health outcomes.
• High‑Risk Rounds:
  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.
• Comfortable with regular home visits and community‑based outreach.
• Demonstrated experience in patient education, care coordination, and social support for high‑risk or geriatric populations.

• Active unrestricted LPN/LVN license or MA certification.
• Licensed or unlicensed medical professional with equivalent foreign RN or physician license.
• Market‑dependent bilingualism in English, Spanish and/or Creole with reading, writing, and speaking proficiency.
• 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.

• Workstyle:
  Combination of clinic‑based and field work (average 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.
• Referral bonus: $750.

This role is patient‑facing and part of Humana's Tuberculosis (TB) screening program. Selected candidates will be required to be screened for TB.

This role requires a valid state driver’s license and personal vehicle liability insurance meeting state minimum limits or $25,000 bodily injury per person / $25,000 bodily injury per event / $10,000 property damage or higher.

• 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…