Integrated Care Coach

Jobtailor; Gastonia (NC); On-site; USD 52,000 - 76,000; Full time

Job summary

Jobtailor is recruiting a fully‑qualified care coordination professional to support high‑risk patients in Gastonia, NC. The role focuses on proactive, patient‑centered coordination across clinics and the community, including home visits and chronic disease education.

You will work with a Care Integration Team to reinforce care plans and bridge gaps between hospital and home settings. This on-site position requires 3+ years in ambulatory or primary care, valid driver’s license, and ability to

Qualifications

• Ambulatory/primary care experience required (3+ years).
• Able to discuss chronic conditions and reinforce meds.
• Comfort with home visits and community outreach.
• Experience in patient education, care coordination, social support for high-risk/geriatric populations.
• Must reside in designated market area; valid state driver’s license and insurance.

Responsibilities

• Provide proactive, patient-centered care coordination and social needs support for the highest-risk top 5% of patient membership.
• Serve as primary patient contact for care coordination, adherence coaching, navigation, transitions of care, and care-plan reinforcement.
• Coordinate care across health and social service systems as patient advocate and clinical support.
• Conduct structured patient interviews and document/share information with providers.
• Perform home visits to observe living conditions and identify safety/social concerns.
• Identify barriers to care and connect patients with community resources.
• Deliver culturally appropriate chronic disease education.
• Liaise among patients, providers, pharmacies, home health, and community providers.
• Support care transitions and close care gaps across care settings.

Skills

Care Coordination

Patient Education

Chronic Disease Management

Home Visit Experience

Population Health

Education

LPN/LVN License (Active, unrestricted)

RN License (Active)

Physician License

Job description

• Provide proactive, patient-centered care coordination and social needs support for the highest-risk top 5% of patient membership
• Serve as the primary patient contact for care coordination, adherence coaching, healthcare navigation, transitions of care, and care-plan reinforcement
• Coordinate care across health and social service systems as a patient advocate and clinical support
• Conduct structured patient interviews and collect, document, and share health-related information with providers
• Perform home visits to observe living conditions and identify safety, environmental, and social concerns
• Identify barriers to care, address immediate social stressors, and connect patients with community-based resources
• Deliver culturally appropriate chronic disease education using approved materials
• Liaise among patients, primary care, specialists, pharmacies, home health, and community providers
• Support care transitions, coordinate follow-up, facilitate communication across care settings, and close care gaps
• Partner with primary care providers to create care plans and priority action items
• Follow up after hospitalizations and emergency department visits; review discharge instructions, arrange follow-up, verify medications, and escalat[e] discrepancies
• Encourage patient connection to community-based programs
• Provide culturally sensitive, patient-centered care
• Develop a holistic understanding of patient needs using the 5Ms framework
• Prepare for, participate in, and discuss patients during High-Risk Rounds
• Travel to patients' homes, healthcare facilities, community-based settings, and assigned clinics
• Work in a combination of clinic-based and field settings, averaging 2 days per week in-center and 2 days per week in-field
• Report to a Care Integration Team Manager within the CenterWell and Conviva Primary Care organization

Requirements

• 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
• Active Unrestricted LPN/LVN license preferred
• Licensed or Unlicensed Medical professional with equivalent foreign Registered Nurse (RN) or Physician license preferred
• Experience in care coordination, case management, population health and/or value-based care models preferred
• Experience conducting post-hospital/ED follow up with appropriate escalation preferred
• Familiarity with Medicaid, Long-term Care, and HCBS programs preferred
• Experience working with seniors and medically complex populations preferred
• Prior home visit experience and knowledge of field safety practices preferred
• Must reside in designated market area
• Valid state driver's license required
• Personal vehicle liability insurance required
• Must complete TB screening if selected
• Ability to work Monday-Friday, 8:00 AM-5:00 PM; overtime may be required

Core Competencies

Demonstrates expertise in patient-centered care coordination, chronic disease education, and community resource navigation for high-risk populations. Proficient in conducting home visits, addressing social determinants of health, and collaborating with healthcare teams to enhance patient outcomes.

Highest-signal resume keywords

• Care Coordination
• Patient Education
• Chronic Disease Management
• Home Visit Experience
• Population Health

ATS Optimization Keywords Hard Skills

• Patient Advocacy
• Care Plan Development
• Medication Reinforcement
• Structured Patient Interviews
• Social Needs Support

Soft Skills

• Cultural Sensitivity
• Communication
• Empathy
• Problem-Solving

Certifications & Qualifications

• Active Unrestricted LPN/LVN License
• Registered Nurse (RN) License
• Physician License

Industry Keywords

• Ambulatory Care
• Primary Care
• Senior Care
• Medicaid
• Long-term Care