Integrated Care Coach

CenterWell•Orange, FL

About The Position

The Integrated Care Coach provides proactive, patient-centered care coordination and social-needs support for the highest-risk 5% of the patient membership. The coach serves as a primary patient contact, focusing on care coordination, adherence coaching, healthcare navigation, transitions of care, and reinforcement of care plans. The position reports to a Care Integration Team Manager within the CenterWell and Conviva Primary Care organization. This mobile role combines clinic-based and field work, including travel to patients’ homes, healthcare facilities, community-based settings, and assigned clinics. The expected work pattern averages two days per week in a center and two days per week in patients’ homes. The employee must reside in the designated market area. Scheduled hours are Monday through Friday, 8:00 a.m. to 5:00 p.m.; overtime may be required. The role is patient-facing and requires TB screening. It is also subject to Humana’s driver safety program, requiring a valid state driver’s license and personal vehicle liability insurance that meets applicable minimum coverage requirements. The position is full-time, with 40 scheduled hours per week. The posted starting base-pay range is $53,700–$72,600 per year, depending on location and job-related qualifications. The role is eligible for a bonus incentive plan based on company and/or individual performance. Humana offers medical, dental, and vision benefits; a 401(k) retirement savings plan; paid time off, company and personal holidays; paid parental and caregiver leave; short- and long-term disability; life insurance; and other benefits. CenterWell Senior Primary Care provides proactive, preventive, personalized care for seniors through integrated care teams and a model that addresses physical, emotional, and social well-being.

Requirements

At least 3 years of ambulatory, primary care, or senior-care experience involving direct patient care.
Ability to discuss chronic conditions and reinforce medication instructions.
Comfort with regularly conducting home visits and community-based outreach.
Demonstrated experience in patient education, care coordination, and social support for high-risk or geriatric populations.
Must reside in the designated market area.
Valid state driver’s license and personal vehicle liability insurance meeting the applicable required minimum limits.
Ability to meet the role’s patient-facing TB screening requirement.

Nice To Haves

Active, unrestricted LPN/LVN license or MA certification.
Licensed or unlicensed medical professional with an equivalent foreign Registered Nurse (RN) or Physician license.
Depending on the market, bilingual English, Spanish, and/or Creole language ability, including reading, writing, and speaking.
Experience in care coordination, case management, population health, and/or value-based care models.
Experience conducting post-hospital or emergency-department 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

Conduct structured patient interviews and gather health-related information, including medication regimens, adherence barriers, social barriers, and functional status.
Document screening findings and share them with providers.
Conduct home visits to observe living conditions, identify safety concerns, and review environmental or social factors affecting patient engagement.
Identify barriers to care, address immediate social stressors, and connect patients with appropriate community-based resources.
Provide culturally appropriate chronic-disease education using approved materials to reinforce provider and pharmacist recommendations.
Coordinate care across patients, primary care providers, specialists, pharmacies, home health, and community providers.
Support transitions of care, coordinate follow-up, and facilitate communication across care settings to close care gaps.
Partner with primary care providers to create care plans and priority action items.
Follow up promptly after hospitalizations and emergency department visits to support safe transitions.
Review discharge instructions, schedule or confirm follow-up appointments, verify patient-reported medications, and escalate discrepancies to providers.
Encourage and support patients’ connections to community-based programs that reinforce health goals, including initial engagement when appropriate.
Provide patient-centered, culturally sensitive care that respects patients’ beliefs, preferences, and social context.
Develop a holistic understanding of patient needs using the 5Ms framework: What Matters Most, Mind (Mentation), Mobility, Medications, and Multi-complexity; identify barriers affecting health outcomes.
Prepare for, participate in, and discuss patients during High-Risk Rounds.
Travel to patients’ homes, healthcare facilities, community-based settings, and assigned clinics.