High-Risk Care Navigator & Adherence Coach

Conviva Senior Primary Care; New Braunfels (TX); Hybrid; USD 54,000 - 73,000; Full time

Job summary

Conviva Senior Primary Care is seeking a Care Coach to provide proactive, patient-centered care coordination and social support for high-risk patients. You will be the primary contact, coordinating care across primary care, specialists, pharmacies, and community resources.

You will conduct home visits, review environments, reinforce care plans, and educate patients on chronic disease management while navigating transitions of care.

Qualifications

• Healthcare professional with 3+ years of ambulatory or senior-care experience with direct patient care.
• Comfortable with home visits and community-based outreach.
• Experience in patient education, care coordination, and social support of high-risk/geriatric populations.
• Ability to discuss chronic conditions and reinforce medication instructions.
• Bilingual in English, Spanish and/or Creole is a plus.

Responsibilities

• Clinical Screening & Escalation: conduct structured patient interviews and document findings.
• Outreach and Home Visits: perform home visits to assess living conditions and barriers.
• Social Needs support: identify barriers to care and connect with community resources.
• Chronic Disease Education: deliver education to reinforce care plans.
• Care Coordination: liaise between patients, providers, pharmacies, and home health.
• Post‑Hospital and ED Follow‑Up: follow up after hospitalizations or ED visits.
• Community Engagement: connect patients with community programs.
• Develop holistic understanding of patient needs using 5Ms framework.
• Prepare, participate and discuss patients during High-Risk Rounds.

Skills

Ambulatory care experience

Home visits

Care coordination

Patient education

Social support

Education

LPN/LVN license or MA certification

Foreign RN/Physician license equivalency

Job description

Conviva Senior Primary Care is seeking a Care Coach to provide proactive, patient-centered care coordination and social support for high-risk patients. You will be the primary contact, coordinating care across primary care, specialists, pharmacies, and community resources.

You will conduct home visits, review environments, reinforce care plans, and educate patients on chronic disease management while navigating transitions of care.