Integrated Care Coach
$53,700–$72,600 year
On-siteFort Lauderdale, Florida, United States
Job Summary
Conduct structured patient interviews, perform home visits to assess living conditions, and deliver culturally appropriate chronic disease education for the highest-risk patient population. Coordinate care across health and social service systems by serving as a liaison between patients, primary care, specialists, and community providers. Manage post-hospital and emergency department follow-ups, verify medication adherence, and escalate discrepancies to providers to close care gaps. Support care transitions, reinforce care plans, and connect patients with community-based resources while maintaining a 5Ms framework for holistic understanding. Work a combination of clinic-based and field roles, including an average of two days per week in-home and two days in-center.
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 and Spanish 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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