Integrated Care Coach

Overview 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 will serve as the primary contact for patients and focus 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. Responsibilities Conduct structured patient interviews and document health information, including medication regimens and barriers to adherence, social and functional status. Perform outreach and home visits to observe living conditions, identify safety concerns, and review environmental or social factors impacting engagement. Identify and address barriers to care, including immediate social stressors, and connect patients with appropriate community resources. Deliver culturally appropriate chronic disease education using approved materials. Serve as a liaison between patients, primary care, specialists, pharmacies, home health, and community providers to support care transitions and coordinate follow‑up. Conduct timely follow‑up after hospitalizations and emergency department visits, reviewing discharge instructions and verifying medication reports. Encourage patient connection to community‑based programs that reinforce health goals. Deliver patient‑centered, culturally sensitive care respecting patients’ beliefs and preferences. Use the 5Ms framework (What Matters Most, Mentation, Mobility, Medications, Multicomplexity) to identify barriers impacting health outcomes. Participate in high‑risk rounds and discuss patient care with the care team. 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. Comfortable with regular 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 RN or physician license. Bilingual in English, Spanish, and/or Creole with ability to read, write, and speak 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. Workstyle and Schedule Combination of clinic‑based and field work (average of 2 days per week in‑center and 2 days per week in‑home). Monday–Friday, 8:00 AM–5:00 PM; overtime may be required. Location Must reside in the Olathe or Wyandotte metro area. Compensation Annual salary range: $53,700–$72,600. This range may vary based on geographic location, experience, education, and certifications. The position offers a bonus incentive plan based on company and/or individual performance. 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 and scholarships for eligible dependents. Parental and caregiver leave. Employee charity matching program. Network Resource Groups (NRGs). Career development opportunities. TB Statement Role is patient‑facing and requires participation in Humana’s Tuberculosis (TB) screening program. Driving Statement Requires a valid state driver’s license and personal vehicle liability insurance in accordance with state minimum limits or higher. Individual must maintain required vehicle insurance. 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. This policy applies to all employment actions. #J-18808-Ljbffr CenterWell Senior Primary Care