Integrated Care Coach

humana; Lake Park (FL); On-site; USD 55,000 - 70,000; Full time

Job summary

Humana's Care Coach role in Lake Park, FL combines clinic-based work with field visits to support high-risk patients using a 5Ms framework. You will coordinate care across primary care, specialists, and community resources, provide education, and help patients navigate barriers to adherence and social needs.

You will travel to patients' homes, perform structured interviews, support care transitions, and play a key role in improving outcomes for geriatric and medically complex populations within

Qualifications

• Healthcare professional with 3+ years of ambulatory, primary care or senior-care patient care.
• Able to discuss chronic conditions and reinforce medication instructions.
• Comfortable with home visits and community outreach.
• Experience in patient education, care coordination, and social support for high‑risk populations.

Responsibilities

• Coordinate care across health and social services, advocating for patients.
• Conduct home visits to assess living conditions and barriers to engagement.
• Identify social needs and connect patients with community resources.
• Deliver chronic disease education and reinforce care plans.
• Serve as liaison among patients, primary care, specialists, and other providers; support transitions of care.
• Follow up after hospitalizations/ED visits to ensure safe transitions and adherence.
• Encourage patient engagement with community programs and ensure culturally competent care.

Skills

Ambulatory care experience

Care coordination

Patient education

Home visits

Geriatrics

Education

LPN/LVN license

MA Certification

RN license

Job description

Become a part of our caring community

***$2,500 SIGN-ON BONUS for new associates! $2,500 payable following 90 days employment. ***

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 escalat 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 M atters Most, M ind (Mentation), M obility, M edications, M ulti-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 or MA Certification
• Licensed or Unlicensed Medical professional with equivalent foreign Registered Nurse (RN) or Physician license
• Market Dependent: Bilingual in English, Spanish and/or Creole with the ability to read/write/speak in both languages
• 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 populationsPrior 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

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.

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 p