Bilingual Integrated Care Coach

CenterWell Senior Primary Care; Las Vegas (NV); On-site; USD 60,000 - 90,000; Full time

Job summary

CenterWell Senior Primary Care is seeking a Care Coach to provide proactive, patient-centered care coordination and social needs support for the highest risk top 5% patient membership. You will be the primary contact for patients, focusing on 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, conducting home visits, coordinating with primary

Qualifications

• Must have healthcare experience in ambulatory/primary care or senior care and be able to discuss chronic conditions.
• Ability to conduct home visits and outreach to communities.
• Experience in patient education, care coordination and supporting high‑risk/geriatric populations.

Responsibilities

• Clinical Screening & Escalation: conduct structured patient interviews and collect health data; share findings with providers.
• Outreach and Home Visits: perform visits to observe living conditions and safety concerns influencing engagement.
• Social Needs support: identify barriers and connect patients with community resources.
• Chronic Disease Education: provide culturally appropriate education to reinforce care plans.
• Care Coordination: liaise between patients, primary care, specialists, pharmacies, home health.
• Post-Hospital and ED Follow-Up: ensure safe transitions and schedule follow-ups.
• Community Engagement: promote connections to community programs supporting health goals.
• Cultural Competence: deliver patient-centered, culturally sensitive care.

Skills

Care coordination

Patient education

Home visits

Social support

Geriatrics

Education

LPN/LVN license or MA Certification

Job description

Become a part of our caring community 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.

Become a part of our caring community 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.

Duties And Responsibilities

• Clinical Screening & Escalation: 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.
• Outreach and Home Visits: Perform home visits to observe living conditions, identify safety concerns, and review environmental or social factors impacting engagement.
• Social Needs support: Identify barriers to care, address immediate social stressors, and connect patients with appropriate community-based resources.
• Chronic Disease Education: Deliver culturally appropriate education using approved materials to reinforce provider and pharmacist recommendations for chronic disease management.
• Care Coordination: 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.
• Post-Hospital and Emergency Department Follow-Up: 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 elevate discrepancies to providers.
• Community Engagement: Encourage and support patient connection to community-based programs that reinforce health goals, including initial engagement when appropriate.
• Cultural Competence: 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

Required Qualifications

• 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

Preferred Qualifications

• 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