Senior Care Navigator & Proactive Care Coach

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

Benefits offered by this job

Bonus incentive plan

Job summary

CenterWell Senior Primary Care seeks a Care Coach to coordinate care across health and social services, perform home visits, and reinforce care plans for high‑risk patients. You will liaise with primary care, specialists, pharmacies, and home health to close care gaps and ensure smooth transitions.

The role emphasizes culturally competent education, outreach, and patient advocacy in a mobile, field-based setting serving seniors with complex health needs.

Qualifications

• 3+ years in ambulatory, primary or senior care with direct patient care.
• Ability to discuss chronic conditions and reinforce medication instructions.
• Comfortable with home visits and community-based outreach.
• Experience in patient education, care coordination, and social support for high‑risk or geriatric populations.

Responsibilities

• Coordinate care across health and social service systems, advocating for patients.
• Perform home visits to assess safety and social factors impacting engagement.
• Identify barriers to care and connect patients with community resources.
• Deliver culturally appropriate education for chronic disease management.
• Liaise between patients, primary care, specialists, pharmacies, home health, and community providers.
• Support care transitions and follow-up, closing care gaps with clinicians.
• Engage with communities to reinforce health goals and post-discharge care.

Skills

Care Coordination

Home Visits

Chronic Disease Education

Bilingual English/Spanish

Patient Education

Education

LPN/LVN license or RN equivalent

MA Certification

Job description

CenterWell Senior Primary Care seeks a Care Coach to coordinate care across health and social services, perform home visits, and reinforce care plans for high‑risk patients. You will liaise with primary care, specialists, pharmacies, and home health to close care gaps and ensure smooth transitions.

The role emphasizes culturally competent education, outreach, and patient advocacy in a mobile, field-based setting serving seniors with complex health needs.