Integrated Care Coach

About the Role 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.

What You'll Do

• Coordinate care across health and social service systems; advocate for patients and provide clinical supports.
• Conduct structured clinical screenings and escalate findings to providers; perform outreach and home visits to assess living conditions and barriers to engagement.
• Provide social needs support and connect patients with community resources; deliver culturally appropriate chronic disease education.
• Serve as liaison among patients, primary care, specialists, pharmacies, home health, and community providers; support care transitions and follow-up to close care gaps.
• Collaborate with primary care providers to develop care plans and action items; conduct timely Post-Hospital and ED follow-up; verify medications and escalate discrepancies.
• Promote community engagement and deliver culturally competent, patient-centered care; apply the 5Ms framework (What Matters Most, Mind, Mobility, Medications, Multi-complexity) to identify barriers.
• Prepare and participate in High-Risk Rounds to discuss patient needs.

What We're Looking For

• Healthcare professional with 3+ years of ambulatory, primary care, or senior-care direct patient care experience.
• Ability to discuss chronic conditions and reinforce medication instructions; comfortable with home visits and community outreach.
• Demonstrated experience in patient education, care coordination, and social support for high-risk or geriatric populations.

Nice to Have

• Active Unrestricted LPN/LVN license or MA certification; licensed/unlicensed medical professional with equivalent foreign RN or physician license.
• Bilingual in English, Spanish, or Creole (read/write/speak) depending on market; experience in care coordination, case management, population health or value-based care models.
• Experience with post-hospital/ED follow-up and escalation; familiarity with Medicaid, Long-term Care, and HCBS programs.
• Experience with seniors and medically complex populations; prior home visits; knowledge of field safety practices.
• Willingness to travel to patients’ homes, healthcare facilities, community settings, and clinics.

Compensation & Benefits

• Benefits including health benefits from day 1, paid time off, holidays, volunteer time, jury duty pay, and more.
• 401(k) with employer match; tuition assistance; scholarships for dependents; parental and caregiver leave; employee charity matching; and career development opportunities.
• This role has a mobile presence and may involve travel; driver’s license and personal vehicle insurance required.