Integrated Care Coach

Centerwell; Gastonia (NC); Hybrid; USD 54,000 - 73,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

401(k) retirement savings

Paid time off

Paid holidays

Parental leave

Life insurance

Disability insurance

Job summary

CenterWell Senior Primary Care is seeking a Care Coach to provide proactive care coordination and social support for the highest risk patients. You will be the primary contact, coordinating care across providers and settings to reinforce care plans and ensure safe transitions.

This role requires home visits, community outreach, and field work with travel to patients’ homes and clinics. Typical hours are Monday–Friday, with some overtime and a designated market area focus.

Qualifications

• Healthcare professional with 3+ years of ambulatory or primary care experience.
• Ability to discuss chronic conditions and reinforce medication instructions.
• Comfort with regular home visits and community outreach.
• Experience in patient education and social support for high-risk or geriatric populations.

Responsibilities

• Coordinate care across health and social services and advocate for patients.
• Perform home visits and assess living conditions.
• Identify barriers to care and connect with community resources.
• Deliver chronic disease education and reinforce care plans.
• Support transitions of care and communicate with providers.

Skills

Patient care

Care coordination

Home visits

Chronic disease education

Cultural competence

Community outreach

Education

LPN/LVN license

RN license or foreign equivalent

Job description

Become a part of our caring community

The Care Coach provides proactive, patient centered care coordination and social needs support for the highest risk top 5% patient membership. You will serve as the primary contact for patients and focuses on care coordination, adherence coaching, healthcare navigation, transitions of care and reinforcing care plans. You will report to a Care Integration Team Manager within the CenterWell and Conviva Primary Care organization.

Duties and Responsibilities

The Care Coach coordinates care across health and social service systems, serving as patient advocates and clinical supports, including but not limited to:

• Clinical Screening & Escalation: Conduct structured patient interviews and collect health-related information (e.g. medication regimen and barriers to adherence, social barriers, functional status.) Document and share findings with providers.
• Outreach and Home Visits: Perform home visits to observe living conditions, identify safety concerns, and review environmental or social factors impacting engagement.
• Social Needs support: Identify barriers to care, address immediate social stressors, and connect patients with appropriate community-based resources.
• Chronic Disease Education: Deliver culturally appropriate education using approved materials to reinforce provider and pharmacist recommendations for chronic disease management.
• Care Coordination: Serve as a liaison between patients, primary care, specialists, pharmacies, home health, and community providers. Support care transitions, coordinate follow-up, and facilitate communication across care settings to close care gaps. Partner closely with the primary care provider to create care plans and priority action items.
• Post‑Hospital and Emergency Department Follow‑Up: Conduct timely follow-up after hospitalizations and emergency department visits to support safe transitions. Review discharge instructions, schedule/confirm follow-up appointments, verify patient reported medications and elevate discrepancies to providers.
• Community Engagement: Encourage and support patient connection to community-based programs that reinforce health goals, including initial engagement when appropriate.
• Cultural Competence: Deliver patient centered, culturally sensitive care that respects patients' beliefs, preferences, and social context.
• Develop a holistic understanding of patient needs via a 5Ms framework (What Matters Most, Mind (Mentation), Mobility, Medications, Multi-complexity) and identify barriers impacting health outcomes.
• Prepare, participate and discuss patients during High‑Risk Rounds

Required 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
• Comfortability to regularly conduct home visits and community-based outreach
• Demonstrated experience in patient education, care coordination, and social support of high-risk or geriatric populations

Preferred Qualifications

• Active Unrestricted LPN/LVN license
• Licensed or Unlicensed Medical professional with equivalent foreign Registered Nurse (RN) or Physician license
• Experience in care coordination, case management, population health and/or value-based care models
• Experience conducting post-hospital/ED follow up with appropriate escalation
• Familiarity with Medicaid, Long-term Care, and HCBS programs
• Experience working with seniors and medically complex populations
• Prior home visit experience and knowledge of field safety practices

Use your skills to make an impact

This role has a mobile presence, involving travel to patients' homes, healthcare facilities, community-based settings, and assigned clinics.

• Workstyle: Combination of clinic-based and field work (expect average of 2 days per week in‑center, and 2 days per week in‑field)
• Location: Must reside in designated market area
• Hours: Monday–Friday, 8:00 AM–5:00 PM; overtime may be required

TB Statement

This role is considered patient facing and is part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.

Driving Statement

This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance. Individual must carry vehicle insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher.

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Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$53,700 - $72,600 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About Us

About CenterWell Senior Primary Care: CenterWell Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. Our unique care model focuses on personalized experiences, taking time to listen, learn and address the factors that impact patient well-being. Our integrated care teams, which include physicians, nurses, behavioral health specialists and more, spend up to 50 percent more time with patients, providing compassionate, personalized care that brings better health outcomes. We go beyond physical health by also addressing other factors that can impact a patient’s well-being.
About CenterWell, a Humana company: CenterWell is a leading healthcare services business focused on creating integrated and differentiated experiences that put our patients at the center of everything we do. The result is high-quality healthcare that is accessible, comprehensive and, most of all, personalized. As the largest provider of senior-focused primary care, a leading provider of home healthcare and a leading integrated home delivery, specialty, hospice and retail pharmacy, CenterWell is focused on whole health and addressing the physical, emotional and social wellness of our patients. CenterWell is part of Humana Inc. (NYSE: HUM). Learn more about what we offer atCenterWell.com.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.