Field-Based Senior Care Coach & Patient Navigator

CenterWell; North Carolina; Hybrid; USD 54,000 - 73,000; Full time

Benefits offered by this job

Sign-on bonus $2,500

Job summary

CenterWell in the United States is seeking a Care Coach to provide proactive, patient-centered care coordination for high-risk patients. You will engage with patients at home and in clinics to reinforce care plans, manage medications, and connect them with community resources.

Responsibilities include screening, escalation, outreach, and collaboration with primary care, pharmacists, and specialists. A background in ambulatory or senior care and ability to conduct home visits are essential.

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
• Comfortable conducting home visits and community outreach
• Experience in patient education, care coordination, and social support of high-risk or geriatric populations

Responsibilities

• Coordinate care across health and social service systems and serve as patient advocates and clinical supports
• Perform home visits to observe living conditions and safety concerns
• Identify barriers to care and connect patients with community resources
• Deliver culturally appropriate education to reinforce chronic disease management
• Serve as liaison between patients, primary care, specialists, pharmacies, and home health
• Support care transitions, schedule follow-ups, and close care gaps
• Conduct timely follow-up after hospitalizations and ED visits
• Encourage engagement with community-based programs

Skills

Ambulatory care

Primary care

Senior care

Patient education

Care coordination

Education

LPN/LVN license

MA certification

RN license (foreign)

Tools

Home visits

Job description

CenterWell in the United States is seeking a Care Coach to provide proactive, patient-centered care coordination for high-risk patients. You will engage with patients at home and in clinics to reinforce care plans, manage medications, and connect them with community resources.

Responsibilities include screening, escalation, outreach, and collaboration with primary care, pharmacists, and specialists. A background in ambulatory or senior care and ability to conduct home visits are essential.