Integrated Care Coach

Company: CenterWell Senior Primary Care
Location: Phoenix
Posted on: March 2, 2026

Job Description:

Become a part of our caring community and help us put health first Job Summary 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. CenterWell clinic locations may be available in the following areas: Wildflower, Glendale, Peoria, Maryvale, Estrella, Golden Hills, South Mountain, Groves, Riverview, West Grand, West Bell, Alhambra, Surprise, Sun City, Goodyear, and Queens Creek. This position requires independent patient outreach (weekly), culturally responsive patient activation, patient advocacy, and coordination with healthcare providers and community partners. You will support patients in navigating complex social and clinical systems, prepares them for provider visits, reinforces care plans in partnership with the patient’s PCP and interdisciplinary team members (including the Integrated Clinical Pharmacist and the Integrated Social Worker), and ensures timely follow-up across care settings, including after hospitalization and emergency department encounters. Duties and Responsibilities 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 M atters Most, M ind (Mentation), M obility, M edications, M ulti-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 Preferred Qualifications 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. Workstyle: Combination of clinic-based and field work (expect average of 2 days per week in-center, and 2 days per week in-home) Location: Must reside in designated market area Hours: Monday–Friday, 8:00 AM–5:00 PM; overtime may be required TB Statement: This role is considered patient facing and is part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB. Driving Statement: This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance. Individual must carry vehicle insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher. 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. $53,700 - $72,600 per year Description of Benefits Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. About Us About CenterWell Senior Primary Care: 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 creates experiences that put patients at the center. As the nation’s largest provider of senior-focused primary care, one of the largest providers of home health services, and fourth largest pharmacy benefit manager, CenterWell is focused on whole-person health by addressing the physical, emotional and social wellness of our patients. As part of Humana Inc. (NYSE: HUM), CenterWell offers stability, industry-leading benefits, and opportunities to grow yourself and your career. We proudly employ more than 30,000 clinicians who are committed to putting health first – for our teammates, patients, communities and company. By providing flexible scheduling options, clinical certifications, leadership development programs and career coaching, we allow employees to invest in their personal and professional well-being, all from day one. ? 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.

Keywords: CenterWell Senior Primary Care, Sun City , Integrated Care Coach, Healthcare , Phoenix, Arizona