Care Coordination Coach for High-Risk Patients

CenterWell Senior Primary Care; Las Vegas (NV); On-site; USD 54,000 - 73,000; Full time

Benefits offered by this job

Bonus incentive plan

Competitive benefits

Job summary

CenterWell Senior Primary Care is seeking a Care Coach to deliver proactive, patient-centered care coordination and social supports for high-risk patients. You will be the primary contact, coordinating care across primary care, specialists, pharmacies, and home health, while reinforcing care plans and adherence.

This role includes home visits, patient education, and community resource connections. The position emphasizes culturally sensitive care, 5Ms framework understanding, and collaboration

Qualifications

• Ambulatory/primary care or senior-care patient care experience.
• Ability to discuss chronic conditions and reinforce medication instructions.
• Comfort conducting home visits and community outreach.

Responsibilities

• Coordinate care across health and social service systems and advocate for patients.
• Conduct home visits to assess living conditions and safety.
• Identify social barriers and connect patients with community resources.
• Deliver chronic disease education using approved materials.
• Support care transitions and coordinate follow-up with providers.
• Engage patients in community-based programs and culturally sensitive care.

Skills

Care coordination

Patient education

Home visits

Chronic disease management

Education

Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN) license

Medical Assistant certification (MA)

Foreign RN or physician license recognized

Job description

CenterWell Senior Primary Care is seeking a Care Coach to deliver proactive, patient-centered care coordination and social supports for high-risk patients. You will be the primary contact, coordinating care across primary care, specialists, pharmacies, and home health, while reinforcing care plans and adherence.

This role includes home visits, patient education, and community resource connections. The position emphasizes culturally sensitive care, 5Ms framework understanding, and collaboration