Integrated Care Coach Educator

CenterWell

3d • Remote

About The Position

Become a part of our caring community and help us put health first The Integrated Care Coach Educator works within the Clinical Education team and is focused on training and educating peers in the High-Risk Patient Management (HRPM) program, focused on Integrated Care Coaches. This role is designed for individuals with lived Integrated Care Coach experience, with lower-level clinical licensure. Working within an interdisciplinary care team, the Integrated Care Coach is responsible for proactively engaging patients identified as high-risk and implementing targeted interventions to increase patient engagement, address social needs and increase access to care. The Integrated Care Coach Educator has a deep understanding of all the High-Risk Patient Management roles and gains the respect and confidence of their peers as a peer educator. This role has a functional understanding of transitions of care management and can effectively complete TCM outreach to patients with recent observation, ED visits, or discharges. The role reports to the Associate Director of Clinical Education, CIT Education lead on a team consisting of interprofessional educators. Primary Responsibilities: Design, develop, and deliver comprehensive onboarding and continuing education programs for Integrated Care Coaches and care integration team members, supporting high-risk patient management, value-based care, population health, and senior care models. Serve as a subject matter expert in care coordination, chronic disease management, social needs navigation, and patient engagement strategies, ensuring education aligns with evolving clinical workflows and care models. Lead education and competency development on the 5Ms Geriatric Framework (What Matters Most, Mind, Mobility, Medications, Multi-complexity) to support holistic patient assessment, care planning, and engagement. Demonstrate expert competence to develop and facilitate field-based training and readiness initiatives, including home visit protocols, community-based patient engagement, situational awareness, and field safety best practices. Design and deliver education that prepares Integrated Care Coaches to effectively support transitions of care workflows, including post-discharge outreach, reinforcement of discharge instructions, medication review support, appointment follow-up coordination, and timely escalation of clinical concerns. Develop and deliver education that prepares Integrated Care Coaches to effectively support patients’ social drivers of health (SDOH), including navigation of housing instability, financial instability, caregiver strain, psychosocial needs, food instability, employment and education access, transportation barriers, and social isolation. Develop chronic disease education curricula to ensure Integrated Care Coaches are equipped to deliver evidence-based patient education, reinforce provider and pharmacy recommendations, and support long-term disease self-management. Develop and deliver training on patient trust-building, motivational interviewing, engagement strategies for resistant or disengaged patients, and techniques to address low health literacy. Monitor performance through direct observation, chart review, data analysis, and call monitoring; provide coaching, feedback, and remediation to ensure quality, compliance, and continuous improvement. Collaborate closely with clinical, operational, compliance, and market leadership to assess training needs, develop program enhancements, and support workforce readiness initiatives. Support onboarding and preceptor programs to ensure smooth transitions for new hires and sustained clinical competency across markets. Maintain limited active Integrated Care Coach practice and/or field engagement (up to 10%) to remain current in clinical workflows and patient care delivery. Use your skills to make an impact

Requirements

• More than 5 years of experience in Integrated Care Coach role and field/community-based supports and interventions
• Demonstrated clinical foundation with ability to effectively translate complex clinical concepts into practical, learner-appropriate education
• Knowledge of community health and social service agencies and resources
• Experience working as part of an interprofessional team
• Experience in training and/or training content development
• Prior experience conducting home visits and knowledge of field safety practices
• Strong knowledge in both social and clinical spaces to promote patient engagement, social needs to be addressed holistically from patient’s perspective, and in creating dynamic care plans.
• Proficient in the following computer skills: Microsoft Office applications, Word and Excel, email, apps, Teams
• Must reside within 50 miles of a PCO market/center
• Ability to travel up to 30%, largely within local and regional markets.

Nice To Haves

• LVN or LPN licensure preferred. Advanced clinical licensure not required.
• Prior experience in working with geriatrics/senior population
• Familiarity with state Medicaid guidelines and application processes
• Preferred experience in care management program/project management or implementation
• Knowledge of EMR/documentation platforms including Salesforce and AthenaOne

Responsibilities

• Design, develop, and deliver comprehensive onboarding and continuing education programs for Integrated Care Coaches and care integration team members, supporting high-risk patient management, value-based care, population health, and senior care models.
• Serve as a subject matter expert in care coordination, chronic disease management, social needs navigation, and patient engagement strategies, ensuring education aligns with evolving clinical workflows and care models.
• Lead education and competency development on the 5Ms Geriatric Framework (What Matters Most, Mind, Mobility, Medications, Multi-complexity) to support holistic patient assessment, care planning, and engagement.
• Demonstrate expert competence to develop and facilitate field-based training and readiness initiatives, including home visit protocols, community-based patient engagement, situational awareness, and field safety best practices.
• Design and deliver education that prepares Integrated Care Coaches to effectively support transitions of care workflows, including post-discharge outreach, reinforcement of discharge instructions, medication review support, appointment follow-up coordination, and timely escalation of clinical concerns.
• Develop and deliver education that prepares Integrated Care Coaches to effectively support patients’ social drivers of health (SDOH), including navigation of housing instability, financial instability, caregiver strain, psychosocial needs, food instability, employment and education access, transportation barriers, and social isolation.
• Develop chronic disease education curricula to ensure Integrated Care Coaches are equipped to deliver evidence-based patient education, reinforce provider and pharmacy recommendations, and support long-term disease self-management.
• Develop and deliver training on patient trust-building, motivational interviewing, engagement strategies for resistant or disengaged patients, and techniques to address low health literacy.
• Monitor performance through direct observation, chart review, data analysis, and call monitoring; provide coaching, feedback, and remediation to ensure quality, compliance, and continuous improvement.
• Collaborate closely with clinical, operational, compliance, and market leadership to assess training needs, develop program enhancements, and support workforce readiness initiatives.
• Support onboarding and preceptor programs to ensure smooth transitions for new hires and sustained clinical competency across markets.
• Maintain limited active Integrated Care Coach practice and/or field engagement (up to 10%) to remain current in clinical workflows and patient care delivery.

Benefits

• Health and Wellness: Comprehensive health, dental, and vision insurance plans to keep you and your family healthy.
• Retirement Savings: Generous 401(k) plan with company match to help you plan for your future.
• Professional Development: Opportunities for continuous learning and development, including access to training programs, certifications, and tuition reimbursement.
• Work-Life Balance: Flexible work arrangements, including remote work options and paid time off to support your personal and professional life.
• Employee Assistance Program: Access to resources and support for personal, financial, and legal matters.
• Wellness Programs: Initiatives to promote physical and mental well-being, including fitness memberships and wellness challenges.
• Community Engagement: Opportunities to participate in volunteer activities and give back to the community.
• Recognition and Rewards: Programs to recognize and reward your contributions and achievements.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed