Integrated Care Coach
$53,700–$72,600 year
On-siteTampa, Florida, United States
Job Summary
Coordinate care across health and social service systems by conducting structured patient interviews, performing home visits to assess living conditions, and delivering culturally appropriate chronic disease education. Serve as a primary contact for high-risk patients, managing care transitions post-hospitalization and emergency department visits while acting as a liaison between patients, primary care providers, and community resources. Identify barriers to care and connect individuals with appropriate community-based programs using the 5Ms framework to address social stressors and reinforce medication adherence.
Required Qualifications
- 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
- Must reside in designated market area
- Must be screened for TB
- Valid state driver's license
- Expected to maintain personal vehicle liability insurance
Desired Qualifications
- 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
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