Senior Care Navigator: In-Home & Care Coordination

CenterWell Senior Primary Care; Gastonia (NC); On-site; USD 54,000 - 73,000; Full time

Benefits offered by this job

Bonus incentive plan

Competitive benefits including medical

401(k) retirement plan

Job summary

CenterWell Senior Primary Care in Gastonia, NC is seeking a Care Coach to provide proactive, patient-centered care coordination for high-risk patients. You will act as the primary contact, conduct home visits, educate patients, and collaborate with primary care teams to close care gaps.

The role emphasizes community outreach, cultural sensitivity, and coordinating with social services to support chronic disease management and safe transitions of care.

Qualifications

• 3+ years of Ambulatory, Primary Care, or Senior-care patient care experience.
• Ability to discuss chronic conditions and reinforce medication instructions.
• Comfort with home visits and community outreach.
• Experience in patient education and care coordination for high-risk or geriatric populations.

Responsibilities

• Coordinate care across health and social services and advocate for patients.
• Conduct structured patient interviews, collect health information, and document findings.
• Perform home visits to assess living conditions and safety.
• Identify barriers to care and connect patients with community resources.
• Deliver chronic disease education and reinforce provider recommendations.
• Facilitate transitions of care and follow-up appointments.
• Support care coordination between primary care, specialists, pharmacies, home health and community providers.
• Engage with patients to improve health outcomes using the 5Ms framework.
• Prepare and participate in High-Risk Rounds.

Skills

Ambulatory care

Primary care

Care coordination

Patient education

Job description

CenterWell Senior Primary Care in Gastonia, NC is seeking a Care Coach to provide proactive, patient-centered care coordination for high-risk patients. You will act as the primary contact, conduct home visits, educate patients, and collaborate with primary care teams to close care gaps.

The role emphasizes community outreach, cultural sensitivity, and coordinating with social services to support chronic disease management and safe transitions of care.