Integrated Care Coach

CenterWell Senior Primary Care

Care Coach providing patient-centered care coordination in health and social service systems. Conducting home visits and supporting patients' social needs for better health outcomes in the United States.

Posted 7/1/2026full-timeSan Antonio • Texas • 🇺🇸 United StatesMid-LevelSenior💰 $53,700 - $72,600 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in care coordination, patient education, and community resource connection, with a strong focus on culturally sensitive care for high-risk and geriatric populations. Proficient in conducting home visits and managing complex patient needs through effective communication and collaboration with healthcare providers.

Highest-signal resume keywords

Care CoordinationPatient EducationHome Visit ExperienceBilingual CommunicationLPN/LVN License

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Chronic Condition ManagementMedication Instruction ReinforcementPatient AdvocacySocial SupportPost-Hospital Follow-UpCare Plan Development5Ms Framework ApplicationCommunity Resource ConnectionCase ManagementPopulation Health

Soft Skills

Cultural SensitivityInterpersonal CommunicationEmpathyProblem SolvingCollaboration

Certifications & Qualifications

Active Unrestricted LPN/LVN LicenseMA Certification

Industry Keywords

Ambulatory CarePrimary CareSenior CareMedicaidLong-term CareHCBS ProgramsGeriatric PopulationsValue-Based Care Models

About the role

Key responsibilities & impact

The Care Coach coordinates care across health and social service systems, serving as patient advocates and clinical supports
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
Perform home visits to observe living conditions, identify safety concerns, and review environmental or social factors impacting engagement
Identify barriers to care, address immediate social stressors, and connect patients with appropriate community-based resources
Deliver culturally appropriate education using approved materials to reinforce provider and pharmacist recommendations for chronic disease management
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
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
Encourage and support patient connection to community-based programs that reinforce health goals
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)

Requirements

What you’ll need

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

Benefits

Comp & perks

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