High-Risk Senior Care Navigator & Home-Visit Coach

CenterWell Senior Primary Care (By Humana); Atlanta (GA); Hybrid; USD 54,000 - 73,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

401(k) retirement plan

Paid time off

Parental and caregiver leave

Disability insurance

Life insurance

Job summary

CenterWell Senior Primary Care in Atlanta, GA seeks a Care Coach to coordinate care, educate patients, and support social needs across health systems. You will travel for home visits and partner with primary care teams to close care gaps.

The role emphasizes culturally competent, patient-centered care, with opportunities to engage diverse populations and support transitions from hospital to home. Flexible clinic/field work is expected.

Qualifications

• Experience in patient education, care coordination, and social support for high-risk populations.
• Ability to conduct outreach and home visits.
• Ability to discuss chronic conditions and support medication adherence.

Responsibilities

• Coordinate care across health and social service systems as a patient advocate.
• Conduct structured interviews, assess barriers to adherence, and document findings.
• Perform home visits to observe living conditions and safety concerns.
• Deliver education to reinforce chronic disease management and medication adherence.
• Facilitate care transitions and coordinate follow-up across settings.

Skills

Patient education

Care coordination

Home visits

Chronic disease management

Cultural competence

Bilingual (English/Spanish or Creole)

Education

Active LPN/LVN license or RN license

Experience with care coordination/population health

Medicaid/HCBS knowledge

Job description

CenterWell Senior Primary Care in Atlanta, GA seeks a Care Coach to coordinate care, educate patients, and support social needs across health systems. You will travel for home visits and partner with primary care teams to close care gaps.

The role emphasizes culturally competent, patient-centered care, with opportunities to engage diverse populations and support transitions from hospital to home. Flexible clinic/field work is expected.