Field-Based Senior Care Navigator

Conviva Senior Primary Care; West Palm Beach (FL); On-site; USD 54,000 - 73,000; Full time

Benefits offered by this job

Sign-on bonus

Travel to patient homes

Benefits package

Job summary

Conviva 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 in Florida. You will serve as the primary contact for patients, coordinating care, conducting home visits, and reinforcing care plans with a focus on transitions of care.

You will travel to patients’ homes and healthcare facilities, work in a hybrid field/clinic setting, and report to a Care Integration Team Manager

Qualifications

• Healthcare professional with 3+ years of ambulatory or senior-care patient care experience.
• Ability to discuss chronic conditions and reinforce medication instructions.
• Comfort with regular home visits and community outreach.
• Experience in patient education, care coordination, and social support for high‑risk or geriatric populations.

Responsibilities

• Conduct structured patient interviews and document health-related information.
• Perform home visits to observe living conditions and safety factors.
• Identify social barriers and connect patients with community resources.
• Deliver education to reinforce chronic disease management.
• Coordinate care between patients, providers, pharmacies, and home health.
• Follow up after hospital or ED visits to support safe transitions.
• Encourage engagement with community programs and address cultural needs.
• Participate in High-Risk Rounds and develop action plans.

Skills

Care coordination

Home visits

Patient education

Social support

Chronic disease education

Healthcare navigation

Adherence coaching

Cultural competence

Education

LPN/LVN license

RN license

MA Certification

Job description

Conviva 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 in Florida. You will serve as the primary contact for patients, coordinating care, conducting home visits, and reinforcing care plans with a focus on transitions of care.

You will travel to patients’ homes and healthcare facilities, work in a hybrid field/clinic setting, and report to a Care Integration Team Manager