- Clinical Screening Escalation: Conduct structured patient interviews collect health-related information document share findings with providers.
- Outreach Home Visits: Perform home visits observe living conditions identify safety concerns review environmental or social factors impacting engagement.
- Social Needs Support: Identify barriers to care address immediate social stressors connect patients with appropriate community-based resources.
- Chronic Disease Education Deliver culturally appropriate education using approved materials reinforce provider pharmacist recommendations chronic disease management}
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Integrated Care Coach - Stone Mountain - CenterWell Senior Primary Care
Description
Become a part of our caring community and help us put health first
The Integrated 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 focusing on care coordination adherence coaching healthcare navigation transitions of care and reinforcing care plans reporting to a Care Integration Team Manager within CenterWell Conviva Primary Care organization.CenterWell clinic locations may be available in Stone Mountain Suwanee Grove Park Greenbriar Victory Heights Woodstock North Augusta West Augusta East Paulding Home Based Care GA Adamsville Marietta Morrow Wesley Chapel Old National
This position requires independent patient outreach weekly culturally responsive patient activation patient advocacy coordination with healthcare providers and community partners supporting patients navigating complex social clinical systems prepares them for provider visits reinforces care plans in partnership with the patients PCP interdisciplinary team members including the Integrated Clinical Pharmacist Integrated Social Worker ensures timely follow-up across care settings including after hospitalization emergency department encounters
Duties Responsibilities
The Care Coach coordinates care across health social service systems serving as patient advocates clinical supports including but not limited to:
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Integrated Care Coach
Only for registered members Stone Mountain
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Integrated Care Coach
Only for registered members Stone Mountain, GA
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Care Coach
Careers Integrated Resources Inc- Atlanta
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Patient Care Coach
Only for registered members Sandy Springs, GA
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Patient Care Coach
Only for registered members Alpharetta, GA
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Home Care Franchise Performance Coach
Only for registered members Atlanta, GA, USA
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Wellness Coach III
Part time Only for registered members Stone Mountain
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Registered Behavior Technician
Only for registered members Stone Mountain
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Clinical Practice Manager
Only for registered members Stone Mountain
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Orthodontic Office Manager
Only for registered members Stone Mountain
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Orthodontic Office Manager
Only for registered members Stone Mountain
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Primary Care Physician
Oak Street Health- Stone Mountain, GA
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Primary Care Physician
Oak Street Health- Stone Mountain, GA
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Nurse Practitioner
Only for registered members Stone Mountain
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Medical Assistant
Only for registered members Stone Mountain
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Medical Assistant
Full time Only for registered members Stone Mountain
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Behavioral Health Specialist Requires LCSW or LPC or LMFT
Full time Only for registered members Stone Mountain
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Registered Behavior Technician
Only for registered members Stone Mountain, GA
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Primary Care Physician
Oak Street Health- Stone Mountain
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Cardiac and Vascular Sonographer
Only for registered members Stone Mountain