Integrated Care Coach
$53,700–$72,600 year
On-siteFloresville, Texas, United States
Job Summary
Conduct structured patient interviews, perform home visits to assess living conditions, and deliver culturally appropriate chronic disease education within CenterWell and Conviva Primary Care. Coordinate care across health and social service systems by serving as a liaison between patients, primary care providers, and community resources to close care gaps. Support safe transitions following hospitalizations and emergency department visits by reviewing discharge instructions and verifying medication adherence. Identify barriers to care and connect high-risk patients with community-based programs using the 5Ms framework. This role requires bilingual proficiency in English and Spanish, with a schedule involving approximately two days per week in-home and two days in-center. Candidates must reside in the designated market area and hold a valid driver's license for field travel.
Required Qualifications
- 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
- Must reside in designated market area
- Valid state driver's license
- Maintain personal vehicle liability insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher
Desired Qualifications
- Active Unrestricted LPN/LVN license or MA Certification
- Licensed or Unlicensed Medical professional with equivalent foreign Registered Nurse (RN) or Physician license
- 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
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