Integrated Care Coach

CenterWell • Atlanta, GA

7h • 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.

Requirements

• Must meet one of the following clinical experience pathways: Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN) background, Registered Nurse (RN), Unlicensed medical professional with equivalent foreign RN or physician license
• Experience in patient education, care coordination, and social support for high-risk populations
• Ability to conduct outreach and home visits
• Ability to discuss chronic conditions and support medication adherence
• Must reside in designated market area
• This role is considered patient facing and is part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.
• This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance. Individual must carry vehicle 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.

Nice To Haves

• Active LPN/LVN license or RN license
• Experience in care coordination, case management, population health, or value-based care
• Knowledge of Medicaid, Long-term Care, and HCBS programs
• Experience with seniors and complex patient populations
• Home visit and field safety experience
• Bilingual in English and Spanish or Creole with full professional proficiency (Market dependent)

Responsibilities

• Coordinates 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 M atters Most, M ind (Mentation), M obility, M edications, M ulti-complexity) and identify barriers impacting health outcomes.
• Prepare, participate and discuss patients during High-Risk Rounds

Benefits

• medical, dental and vision benefits
• 401(k) retirement savings plan
• time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
• short-term and long-term disability
• life insurance

What This Job Offers

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