In-Home Care Navigator for High-Risk Patients

CenterWell Senior Primary Care; Virginia (MN); On-site; USD 54,000 - 73,000; Full time

Benefits offered by this job

Health insurance

401(k) retirement savings plan

Paid time off

Job summary

CenterWell Senior Primary Care seeks a Care Coach to provide proactive, patient-centered care coordination for high-risk seniors. You will serve as the primary contact, coordinating care plans and ensuring smooth transitions across care settings.

The role requires conducting home visits, patient education, and collaboration with primary care teams, specialists, and community resources. Travel to patient homes and clinics is expected.

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.
• Comfortable with regularly conducting 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 as patient Advocate and clinical support.
• Conduct structured patient interviews and document health-related information for providers.
• Perform home visits to observe living conditions and identify safety concerns.
• Identify barriers to care and connect patients with community resources.
• Deliver chronic disease education using approved materials to reinforce care plans.
• Serve as a liaison between patients, primary care, specialists, pharmacies, and home health.
• Support care transitions, schedule follow-ups, and close care gaps.
• Participate in High-Risk Rounds and coordinate action items with the care team.
• Promote patient engagement with community programs and culturally respectful care.

Skills

Care coordination

Patient education

Home visits

Chronic disease management

Cultural competence

5Ms framework

Interdisciplinary collaboration

Job description

CenterWell Senior Primary Care seeks a Care Coach to provide proactive, patient-centered care coordination for high-risk seniors. You will serve as the primary contact, coordinating care plans and ensuring smooth transitions across care settings.

The role requires conducting home visits, patient education, and collaboration with primary care teams, specialists, and community resources. Travel to patient homes and clinics is expected.