High-Risk Care Navigator & Coordinator

CenterWell Senior Primary Care; Dallas (TX); Hybrid; USD 54,000 - 73,000; Full time

Job summary

CenterWell Senior Primary Care in the Dallas market seeks a Care Coach to provide proactive, patient-centered care coordination and social needs support for the highest risk top 5% patients. You will serve as the primary contact for patients and focus on care coordination, adherence coaching, healthcare navigation, transitions of care and reinforcing care plans.

The role involves a mobile presence with travel to patients' homes, clinics, and community settings.

Qualifications

• 3+ years in ambulatory, primary care, or senior-care with direct patient care.
• Ability to discuss chronic conditions and reinforce medication instructions.
• Comfortable with regular home visits and community-based 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.
• Conduct structured patient interviews and document findings.
• Perform home visits to assess living conditions and safety.
• Identify barriers to care and connect to community resources.
• Deliver chronic disease education reinforcing provider recommendations.
• Liaise between patients, primary care, specialists, pharmacies and home health.
• Support care transitions and follow-up appointments; close care gaps.
• Support patient engagement with culturally sensitive care.

Skills

Ambulatory care

Chronic conditions

Home visits

Patient education & coordination

Education

LPN/LVN license or MA certification

Job description

CenterWell Senior Primary Care in the Dallas market seeks a Care Coach to provide proactive, patient-centered care coordination and social needs support for the highest risk top 5% patients. You will serve as the primary contact for patients and focus on care coordination, adherence coaching, healthcare navigation, transitions of care and reinforcing care plans.

The role involves a mobile presence with travel to patients' homes, clinics, and community settings.