Centerwell Senior Primary Care
Healthcare
IntegratedCareCoach
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“Integrated Care Coach at Centerwell Senior Primary Care. Skills: Care coordination, Patient advocacy, Social needs support. Provide proactive patient centered care coordination. Serve as primary contact for patients”
What You'll Achieve.
Proactive, patient centered care coordination; Social needs support for highest risk top 5% patient membership; Better health outcomes
Industry & Context.
Identify barriers to care; Address immediate social stressors; Identify safety concerns; Identify barriers impacting health outcomes
Must reside in designated market area, Valid state driver's license, Maintain personal vehicle liability insurance, TB screening required, Travel to patients' homes, healthcare facilities, community-based settings, and assigned clinics
What They're Looking For.
Must Have
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, 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
Nice to Have
Active Unrestricted LPN/LVN license or MA Certification, Licensed or Unlicensed Medical professional with equivalent foreign Registered Nurse (RN) or Physician license, Market Dependent: Bilingual in English, Spanish and/or Creole with the ability to read/write/speak in both languages, Experience in care coordination, case management, population health and/or value-based care models, Experience conducting post-hospital/ED follow up with appropriate escalation, Familiarity with Medicaid, Long-term Care, and HCBS programs, Experience working with seniors and medically complex populations, Prior home visit experience and knowledge of field safety practices
What You'll Do.
Provide proactive patient centered care coordination
Serve as primary contact for patients
Focus on care coordination
Provide adherence coaching
Provide healthcare navigation
Manage transitions of care
Conduct structured patient interviews
Collect health-related information
Document and share findings with providers
Identify safety concerns
Connect patients with community resources
Deliver culturally appropriate education
Serve as liaison between patients and providers
Support care transitions
Facilitate communication across care settings
Conduct timely follow-up after hospitalizations
Review discharge instructions
Schedule/confirm follow-up appointments
Verify patient reported medications
Encourage patient connection to community programs
Deliver patient centered
culturally sensitive care
Develop holistic understanding of patient needs
Discuss patients during High-Risk Rounds
How You'll Work.
Team & Collaboration
Serve as liaison between patients, primary care, specialists, pharmacies, home health, and community providers; Partner closely with the primary care provider to create care plans and priority action items; Document and share findings with providers; Escalate discrepancies to providers
Communication Scope
Ability to discuss chronic conditions; Reinforce medication instructions; Culturally appropriate education; Facilitate communication across care settings
Full Job Description
# **Become a part of our caring community** The Care Coach provides 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 focuses on care coordination, adherence coaching, healthcare navigation, transitions of care and reinforcing care plans. You will report to a Care Integration Team Manager within the CenterWell and Conviva Primary Care organization. **Duties and Responsibilities** The Care Coach coordinates care across health and social service systems, serving as patient advocates and clinical supports, including but not limited to: * **Clinical Screening & Escalation:** Conduct structured patient interviews and collect health-related information (e.g. medication regimen and barriers to adherence, social barriers, functional status.) Document and share findings with providers. * **Outreach and Home Visits:** Perform home visits to observe living conditions, identify safety concerns, and review environmental or social factors impacting engagement. * **Social Needs support:** Identify barriers to care, address immediate social stressors, and connect patients with appropriate community-based resources. * **Chronic Disease Education:** Deliver culturally appropriate education using approved materials to reinforce provider and pharmacist recommendations for chronic disease management. * **Care Coordination:** Serve as a liaison between patients, primary care, specialists, pharmacies, home health, and community providers. Support care transitions, coordinate follow-up, and facilitate communication across care settings to close care gaps. Partner closely with the primary care provider to create care plans and priority action items. * **Post‑Hospital and Emergency Department Follow‑Up** : Conduct timely follow-up after hospitalizations and emergency department visits to support safe transitions. Review discharge instructions, schedule/confirm follow-up
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