Become a part of our caring community and help us put health first

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.

This position requires independent patient outreach (weekly) culturally responsive patient activation patient advocacy and coordination with healthcare providers and community partners. You will support patients in navigating complex social and clinical systems prepares them for provider visits reinforces care plans in partnership with the patients PCP and interdisciplinary team members (including the Integrated Clinical Pharmacist and the Integrated Social Worker) and ensures timely follow-up across care settings including after hospitalization and emergency department encounters.

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.
• PostHospital and Emergency Department FollowUp: Conduct timely follow-up after hospitalizations and emergency department visits to support safe transitions. Review discharge instructions schedule/confirm follow-up appointments verify patient reported medications and escalate discrepancies to providers.
• Community Engagement: Encourage and support patient connection to community-based programs that reinforce health goals including initial engagement when appropriate.
• Cultural Competence: Deliver patient centered culturally sensitive care that respects patients beliefs preferences and social context.

• Develop a holistic understanding of patient needs via a 5Ms framework (What Matters Most Mind (Mentation) Mobility Medications Multi-complexity) and identify barriers impacting health outcomes.
• Prepare participate and discuss patients during High-Risk Rounds

Required Qualifications

• Healthcare professional with 3 years of Ambulatory Primary Care or SeniorCare 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

Preferred Qualifications

• 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

Use your skills to make an impact

This role has a mobile presence involving travel to patients homes healthcare facilities community-based settings and assigned clinics.

• Workstyle: Combination of clinic-based and field work (expect average of 2 days per week in-center and 2 days per week in-home)
• Location: Must reside in designated market area
• Hours: MondayFriday 8:00 AM5:00 PM; overtime may be required

TB Statement:

This role is considered patient facing and is part of Humanas Tuberculosis (TB) screening program. If selected for this role you will be required to be screened for TB.

Driving Statement:

This role is part of Humanas driver safety program and therefore requires an individual to have a valid state drivers license and are expected to maintain personal vehicle liability insurance. Individual must carry vehicle insurance in accordance with their residing state minimum required limits or $25000 bodily injury per person/$25000 bodily injury per event /$10000 for property damage or whichever is higher.

Alert:

Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number if it is not already on file. When required an email will be sent from with instructions on how to add the information into your official application on Humanas secure website.

Interview Format: HireVue:

As part of our hiring process for this opportunity we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

Benefits:

Humana offers a variety of benefits to promote the best health and well-being of our employees and their families. We design competitive and flexible packages to give our employees a sense of financial securityboth today and in the future including:

• Health benefits effective day 1

• Paid time off holidays volunteer time and jury duty pay

• Recognition pay

• 401(k) retirement savings plan with employer match

• Tuition assistance

• Scholarships for eligible dependents

• Parental and caregiver leave

• Employee charity matching program

• Network Resource Groups (NRGs)

• Career development opportunities

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Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills knowledge experience education certifications etc.

$53700 - $72600 per year

Description of Benefits

Humana Inc. and its affiliated subsidiaries (collectively Humana) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits Humana provides medical dental and vision benefits 401(k) retirement savings plan time off (including paid time off company and personal holidays volunteer time off paid parental and caregiver leave) short-term and long-term disability life insurance and many other opportunities.

About Us

About CenterWell Senior Primary Care: CenterWell Senior Primary Care provides proactive preventive care to seniors including wellness visits physical exams chronic condition management screenings minor injury treatment and more. Our unique care model focuses on personalized experiences taking time to listen learn and address the factors that impact patient well-being. Our integrated care teams which include physicians nurses behavioral health specialists and more spend up to 50 percent more time with patients providing compassionate personalized care that brings better health outcomes. We go beyond physical health by also addressing other factors that can impact a patients well-being.

About CenterWell a Humana company: CenterWell creates experiences that put patients at the center. As the nations largest provider of senior-focused primary care one of the largest providers of home health services and fourth largest pharmacy benefit manager CenterWell is focused on whole-person health by addressing the physical emotional and social wellness of our patients. As part of Humana Inc. (NYSE: HUM) CenterWell offers stability industry-leading benefits and opportunities to grow yourself and your career. We proudly employ more than 30000 clinicians who are committed to putting health first for our teammates patients communities and company. By providing flexible scheduling options clinical certifications leadership development programs and career coaching we allow employees to invest in their personal and professional well-being all from day one.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race color religion sex sexual orientation gender identity national origin age marital status genetic information disability or protected veteran status. It is also the policy of Humana to take affirmative action in compliance with Section 503 of the Rehabilitation Act and VEVRAA to employ and to advance in employment individuals with disability or protected veteran status and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions including but not limited to recruitment hiring upgrading promotion transfer demotion layoff recall termination rates of pay or other forms of compensation and selection for training including apprenticeship at all levels of employment.