CenterWell·Houston, Texas
The Care Coach provides proactive, patient-centered care coordination and social needs support for high-risk patients. Key duties include conducting home visits, managing chronic disease education, and facilitating transitions of care between providers and facilities.
Become a part of our caring community 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.
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. Post‑Hospital and Emergency Department Follow‑Up: 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 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
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.
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 security—both 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 #LI-BL1 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.
$59,100 - $79,900 per year
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 patient’s well-being.
About
CenterWell, a
Humana company: CenterWell is a leading healthcare services business focused on creating integrated and differentiated experiences that put our patients at the center of everything we do. The result is high-quality healthcare that is accessible, comprehensive and, most of all, personalized. As the largest provider of senior-focused primary care, a leading provider of home healthcare and a leading integrated home delivery, specialty, hospice and retail pharmacy, CenterWell is focused on whole health and addressing the physical, emotional and social wellness of our patients. CenterWell is part of Humana Inc. (NYSE: HUM). Learn more about what we offer at CenterWell.com. 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.
Requires a healthcare professional with over 3 years of experience in ambulatory, primary, or senior care with direct patient experience. Candidates must be comfortable conducting home visits and have demonstrated skill in supporting high-risk or geriatric populations.
Market context
In Texas, Integrated Care Coach roles are often competitive because they combine ambulatory or primary care experience with direct patient support, home visits, and education for high-risk populations. Candidates with a healthcare background and strong social support skills may stand out, especially when they can show comfort working across care settings. Review the AI-summarized requirements and benefits here to save time, then tailor your application to highlight patient education, home-visit readiness, and relevant care experience.
