Conviva Senior Primary Care
Healthcare
IntegratedCareCoach
Neural analysis suggests this role is
optimal for Mid candidates.
“Integrated Care Coach at Conviva Senior Primary Care. Skills: Patient care coordination, Social needs support, Chronic disease education. Provide proactive, patient centered care coordination. Serve as primary contact for patients”
Industry & Context.
Identify barriers to care; Address immediate social stressors; Identify barriers impacting health outcomes
Regularly conduct home visits, Involves travel to patients' homes, healthcare facilities, community-based settings, and assigned clinics, TB screening required, Must maintain personal vehicle liability insurance
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, Valid state driver's license, Personal vehicle liability insurance
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, 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.
patient centered care coordination
Serve as primary contact for patients
Coordinate care across health and social service systems
Conduct structured patient interviews
Perform home visits to identify safety concerns
Connect patients with community-based resources
Deliver education for chronic disease management
Serve as liaison between patients and providers
Support care transitions and coordinate follow-up
Conduct follow-up after hospitalizations and ED visits
Encourage patient connection to community programs
Deliver patient centered
culturally sensitive care
Develop holistic understanding of patient needs
Participate in High-Risk Rounds
How You'll Work.
Team & Collaboration
Document and share findings with providers; 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
Communication Scope
Ability to discuss chronic conditions; Reinforce medication instructions; Culturally appropriate education delivery; 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 follow-up after hospitalizations and emergency department visits to support safe transitions. Review discharge instructions, schedule/confirm follow-up appoin
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