High-Risk Care Coach: Home Visits & Care Coordination

Humana Inc; Jacksonville (FL); Hybrid; USD 54,000 - 73,000; Full time

Job summary

Humana Inc. and Conviva Senior Primary Care seek 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 and coordinate care across providers, transitions of care, and follow-up.

This role requires travel to patients' homes and clinics within the designated market area. You will conduct structured interviews, support adherence, and connect patients with community

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.

Responsibilities

• Coordinate care across health and social service systems, serving as a patient advocate and clinical support.
• Conduct structured patient interviews and document findings for providers.
• Perform home visits to observe living conditions and safety concerns.
• Identify barriers to care and connect patients with community resources.
• Deliver chronic disease education using approved materials.
• Serve as a liaison between patients, primary care, specialists, pharmacies, home health, and community providers.
• Support care transitions, coordinate follow-up, and close care gaps.
• Conduct post-hospital and ED follow-up to ensure safe transitions.
• Encourage and support patient connection to community-based programs and deliver culturally sensitive care.
• Develop a holistic understanding of patient needs via the 5Ms framework and identify barriers to health outcomes.
• Prepare, participate in and discuss patients during High-Risk Rounds.

Skills

Ambulatory care

Primary care

Senior-care experience

Patient education

Care coordination

Social support

Home visits

Education

LPN/LVN license

RN license

MA Certification

Medicaid familiarity

Job description

Humana Inc. and Conviva Senior Primary Care seek 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 and coordinate care across providers, transitions of care, and follow-up.

This role requires travel to patients' homes and clinics within the designated market area. You will conduct structured interviews, support adherence, and connect patients with community