Integrated Care Coach

Join 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 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 CenterWell and Conviva Primary Care organization.

Duties and Responsibilities

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 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

Required Qualifications

• 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

Preferred 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

Use Your Skills to Make an Impact

Must meet one of the following clinical experience pathways:

• Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN) background
• Medical Assistant with at least 3 years of primary care, outpatient or ambulatory settings
• Non-licensed healthcare professional with 3+ years of direct patient care experience
• Unlicensed medical professional with equivalent foreign RN or physician license

Required Qualifications:

• Experience in patient education, care coordination, and social support for high-risk populations
• Ability to conduct outreach and home visits
• Ability to discuss chronic conditions and support medication adherence

Language:

• Bilingual in English and Spanish or Creole with full professional proficiency (Market dependent)

Preferred Qualifications:

• Active LPN/LVN license or MA certification
• Experience in care coordination, case management, population health, or value-based care
• Knowledge of Medicaid, Long-term Care, and HCBS programs
• Experience with seniors and complex patient populations
• Home visit and field safety experience

Scheduled Weekly Hours: 40

Pay Range: $53,700 - $72,600 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits: Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

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, minor injury treatment and more. As part of Humana's Primary Care Organization, which includes CenterWell Senior Primary Care, Conviva's innovative, value-based approach means each patient gets the best care, when needed most, and for the lowest cost. We go beyond physical health – addressing the social, emotional, behavioral and financial needs that can impact our patients' 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.

Equal Opportunity Employer: It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.