Integrated Care Coach (Deerfield Beach)

CenterWell•Fort Lauderdale, FL

22h•Hybrid

About The Position

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. 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. 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).

Requirements

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
Must reside in designated market area
Have a valid state driver's license
Maintain personal vehicle liability insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher
Be screened for TB (if selected for this role)

Nice To Haves

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

Responsibilities

Coordinate care across health and social service systems, serving as patient advocates and clinical supports.
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.
Perform home visits to observe living conditions, identify safety concerns, and review environmental or social factors impacting engagement.
Identify barriers to care, address immediate social stressors, and connect patients with appropriate community-based resources.
Deliver culturally appropriate education using approved materials to reinforce provider and pharmacist recommendations for chronic disease management.
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.
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.
Encourage and support patient connection to community-based programs that reinforce health goals, including initial engagement when appropriate.
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