Integrated Care Coach
$53,700–$72,600 year
On-siteDelray Beach, Florida, United States
Delray Beach, Florida, United StatesOn-siteFull Time$53,700–$72,600 yearHEALTHCARELarge
Full TimeLargeHEALTHCARE
Job Summary
Conduct structured patient interviews, perform home visits to assess living conditions, and deliver culturally appropriate chronic disease education for high-risk senior populations. Coordinate care across health and social service systems by serving as a liaison between patients, primary care providers, and community resources. Manage post-hospital and emergency department follow-ups to support safe transitions, while identifying social barriers and connecting patients with community-based programs. Work Monday through Friday with a mobile presence involving travel to clinics and patients' homes.
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
- Must have a valid state driver's license
- Must maintain personal vehicle liability insurance in accordance with state minimums 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
- 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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