High-Risk Care Coach & Patient Navigator

CenterWell Senior Primary Care; Houston (TX); Hybrid; USD 59,100 - 79,900; Full time

Benefits offered by this job

Health benefits day 1

Paid time off

401(k) retirement plan with employer’s

Tuition assistance

Job summary

CenterWell Senior Primary Care is seeking a Care Coach to coordinate care for the highest risk top 5% patient members. You will be the primary contact for patients, performing care coordination, adherence coaching, healthcare navigation, and facilitating transitions of care.

You will report to a Care Integration Team Manager within the CenterWell and Conviva Primary Care organization. The role involves mobile work with travel to patients’ homes, clinics and community settings; typical hours are

Qualifications

• 3+ years in ambulatory, primary care, or senior care with direct patient care.
• Ability to conduct home visits and community outreach.
• Experience in patient education, care coordination and social support for high‑risk or geriatric populations.
• Willingness to travel and provide patient-centered care.

Responsibilities

• Coordinate care across health and social services; advocate for patients.
• Perform home visits to assess living conditions and safety.
• Identify barriers to care and connect to community resources.
• Provide chronic disease education and reinforce care plans.
• Support care transitions and follow-up across settings.

Skills

Care coordination

Home visits

Patient education

Care navigation

Multidisciplinary collaboration

Education

LPN/LVN license

MA Certification

RN/MD license equivalence

Job description

CenterWell Senior Primary Care is seeking a Care Coach to coordinate care for the highest risk top 5% patient members. You will be the primary contact for patients, performing care coordination, adherence coaching, healthcare navigation, and facilitating transitions of care.

You will report to a Care Integration Team Manager within the CenterWell and Conviva Primary Care organization. The role involves mobile work with travel to patients’ homes, clinics and community settings; typical hours are