Integrated Care Coach

Care Coach – Role Overview The Care Coach provides proactive, patient‑centered care coordination and social needs support for the highest‑risk top 5% patient membership. Responsibilities Clinical Screening & Escalation: Conduct structured patient interviews and collect health‑related information (e.g., medication regimen and barriers to adherence, social barriers, functional status) and document/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 to close care gaps. 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 elevate 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. Prepare, participate, and discuss patients during High‑Risk Rounds. Qualifications Healthcare professional with 3+ years of Ambulatory, Primary Care, or Senior‑Care experience with direct patient care. Bilingual in English and Spanish with the ability to read/write/speak in both languages. 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 credentials, Registered Nurse (RN) or Physician license. 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 of 2 days per week in‑center and 2 days per week in‑home). Mobile presence involving travel to patients’ homes, healthcare facilities, community‑based settings, and assigned clinics. Location Must reside in designated market area. Hours Monday–Friday, 8:00AM–5:00PM; overtime may be required. TB Screening This role is considered patient‑facing and is part of Humana’s Tuberculosis (TB) screening program. If selected, you will be required to be screened for TB. Driving Requires a valid state driver’s license and maintenance of personal vehicle liability insurance with minimum limits of $25,000 bodily injury per person/$25,000 bodily injury per event/$10,000 property damage or higher. 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 Compensation Pay range: $53,700 – $72,600 per year (full‑time, 40 hours per week). Eligible for a bonus incentive plan based on company and/or individual performance. 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. #J-18808-Ljbffr