Integrated Care Coach - Nashville - CenterWell Senior Primary Care

    CenterWell Senior Primary Care
    Description

    Become a part of our caring community and help us put health first

    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 focusing on care coordination adherence coaching healthcare navigation transitions of care reinforcing care plans reporting to a Care Integration Team Manager within CenterWell Conviva Primary Care organization.
    CenterWell clinic locations may be available in Gallatin Tusculum Lebanon Bordeaux Madison Hermitage Bellevue Smyrna Murfreesboro Clarksville.
    This position requires independent patient outreach weekly culturally responsive patient activation patient advocacy and coordination with healthcare providers community partners. Supports patients navigating complex social clinical systems prepares them for provider visits reinforces care plans in partnership with PCP interdisciplinary team members Integrated Clinical Pharmacist Integrated Social Worker ensures timely follow-up across care settings including after hospitalization emergency department encounters.

    Duties Responsibilities

    • 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 address immediate stressors connect patients appropriate resources.
    • Chronic Disease Education Deliver culturally appropriate education approved materials reinforce recommendations chronic disease management.
    This role has mobile presence involving travel to patients homes facilities community-based settings assigned clinics Workstyle combination clinic field work expect average days week in-center days week in-home Location must reside designated market area Hours Monday–Friday AM–PM overtime required TB Statement Considered Tuberculosis screening program selected this role you required screened Cultural Competence:Patient centered delivery that respects beliefs preferences social context Delivers via framework (Matters Most M ind Mobility Medications Multi-complexity) identifies impacting outcomes Participates High-Risk RoundsRequired Qualifications-Healthcare professional Ambulatory Senior-Care experience direct patient-Experience discussing condition medication instructions Comfortability conducting home visits Community-Based Outreach-Demonstrated Patient Education Coordination Social Support high-risk geriatric populations Preferred qualifications include Active LPN/LVN MA Certification Market Dependent Bilingual English Spanish Creole abilities.

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    Integrated Care Coach

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    Become a part of our caring community and help us put health first · 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 ca ...

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