Senior Care Navigator & Home-Visit Specialist

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

Benefits offered by this job

Medical, dental and vision benefits

401(k) retirement savings plan

Paid time off

Job summary

CenterWell Senior Primary Care is seeking a Care Coach to provide 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 coordinate care across providers, pharmacies, and community resources.

Responsibilities include conducting structured interviews, performing home visits, and delivering education to reinforce treatment plans.

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
• Comfortable conducting home visits and community-based outreach
• Experience in patient education, care coordination, and social support of high‑risk or geriatric populations

Responsibilities

• Conduct structured patient interviews and document findings for providers
• Perform home visits to assess living conditions and safety
• Identify barriers to care and connect patients with community resources
• Deliver culturally appropriate chronic disease education
• Coordinate care across primary care, specialists, pharmacies, and home health
• Follow up after hospitalizations and ED visits to support safe transitions
• Engage community resources to support health goals
• Work with 5Ms framework to understand patient needs
• Prepare and participate in High-Risk Rounds

Skills

Ambulatory care

Care coordination

Home visits

Patient education

Chronic disease management

Job description

CenterWell Senior Primary Care is seeking a Care Coach to provide 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 coordinate care across providers, pharmacies, and community resources.

Responsibilities include conducting structured interviews, performing home visits, and delivering education to reinforce treatment plans.