Integrated Care Coach

**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.

**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 vi...