Senior Care Navigator & Home-Visit Coach

CenterWell Senior Primary Care; Charlotte (NC); Hybrid; USD 54,000 - 73,000; Full time

Job summary

CenterWell Senior Primary Care is seeking a Care Coach to provide proactive, patient-centered care coordination for high‑risk seniors. You will serve as the primary contact, conduct home visits, reinforce care plans, and support transitions across care settings.

Responsibilities include social needs support, chronic disease education, and collaboration with primary care teams to close care gaps. Must reside in designated market area and be flexible for clinic/field work.

Qualifications

• Ambulatory/primary care experience with direct patient care (3+ years).
• Ability to discuss chronic conditions and reinforce medication instructions.
• Willingness to conduct home visits and community outreach.
• Experience in patient education, care coordination, and social support for high-risk/geriatric populations.

Responsibilities

• Coordinate care across health and social service systems; act as patient advocate and clinical support.
• Conduct structured patient interviews and document findings for providers.
• Perform home visits to assess living conditions and safety concerns.
• Identify barriers to care and connect patients with community resources.
• Support care transitions and follow-up across care settings to close gaps.

Skills

Care coordination

Patient education

Home visits

Chronic disease management

Education

LPN/LVN license (Active)

Job description

CenterWell Senior Primary Care is seeking a Care Coach to provide proactive, patient-centered care coordination for high‑risk seniors. You will serve as the primary contact, conduct home visits, reinforce care plans, and support transitions across care settings.

Responsibilities include social needs support, chronic disease education, and collaboration with primary care teams to close care gaps. Must reside in designated market area and be flexible for clinic/field work.