Senior Care Coordination Navigator

Humana Inc; Virginia (MN); Hybrid; USD 54,000 - 73,000; Full time

Benefits offered by this job

Medical, dental, vision benefits

401(k) retirement savings plan

Paid time off & holidays

Parental and caregiver leave

Disability and life insurance

Job summary

Humana Inc. through CenterWell Senior Primary Care seeks a Care Coach to provide proactive, patient-centered care coordination and social needs support for high-risk patients.

You will serve as the primary contact, conduct home visits, and reinforce care plans, working across primary care, specialists, pharmacies, and home health to close care gaps. The role emphasizes chronic disease education, cultural competence, and post-hospital follow-up, with travel to patients’ homes and clinics; a

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.
• Willingness to conduct home visits and community outreach.

Responsibilities

• Conduct structured patient interviews and document findings.
• Perform home visits to assess living conditions and barriers.
• Identify social barriers and connect with community resources.
• Deliver chronic disease education using approved materials.
• Coordinate care between patients, primary care, specialists, pharmacies, and home health.
• Follow up after hospitalizations and ED visits to ensure safe transitions.
• Engage with community programs to support health goals.
• Apply a 5Ms framework to assess patient needs.

Skills

Ambulatory care experience

Care coordination

Patient education

Geriatric care

Education

LPN/LVN license or MA Certification

Job description

Humana Inc. through CenterWell Senior Primary Care seeks a Care Coach to provide proactive, patient-centered care coordination and social needs support for high-risk patients.

You will serve as the primary contact, conduct home visits, and reinforce care plans, working across primary care, specialists, pharmacies, and home health to close care gaps. The role emphasizes chronic disease education, cultural competence, and post-hospital follow-up, with travel to patients’ homes and clinics; a