Senior Care Navigator — In-Home & Care Coordination

Humana Inc; Orange City (FL); Ibrido; USD 54.000 - 73.000; Tempo pieno

Descrizione del lavoro

Humana Inc. Conviva Senior Primary Care in Florida seeks a Care Coach to provide proactive, patient-centered care coordination for high-risk seniors. You will be the primary contact for patients and work across care settings to close gaps in care.

You will conduct home visits, deliver chronic disease education, support adherence, and connect patients with community resources. This role requires bilingual English/Spanish, 3+ years in ambulatory care, and strong care coordination skills.

Competenze

• Healthcare professional with 3+ years of ambulatory, primary care, or senior-care experience with direct patient care
• Bilingual in English and Spanish with the ability to read/write/speak in both languages
• 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

Mansioni

• Coordinate care across health and social services as a primary contact for patients and focuses on care coordination and adherence coaching.
• Conduct structured patient interviews and collect health-related information, documenting and sharing findings with providers.
• Perform home visits to observe living conditions, safety concerns, and environmental or social factors impacting engagement.
• Deliver culturally appropriate education to reinforce provider and pharmacist recommendations for chronic disease management.
• Serve as a liaison between patients, primary care, specialists, pharmacies, home health, and community providers to close care gaps.
• Support care transitions, coordinate follow-up, and facilitate communication across care settings.
• Follow up after hospitalizations and emergency department visits to support safe transitions and verify medications.
• Encourage and support patient connection to community-based programs that reinforce health goals.
• Develop a holistic understanding of patient needs via the 5Ms framework and identify barriers impacting health outcomes.
• Prepare, participate and discuss patients during High-Risk Rounds

Conoscenze

Care coordination

Patient education

Bilingual English/Spanish

Home visits

Descrizione del lavoro

Humana Inc. Conviva Senior Primary Care in Florida seeks a Care Coach to provide proactive, patient-centered care coordination for high-risk seniors. You will be the primary contact for patients and work across care settings to close gaps in care.

You will conduct home visits, deliver chronic disease education, support adherence, and connect patients with community resources. This role requires bilingual English/Spanish, 3+ years in ambulatory care, and strong care coordination skills.