About CenterWell Senior Primary Care
CenterWell Senior Primary Care is a comprehensive network of doctor’s offices dedicated to providing holistic, one-stop care for Medicare and Medicare Advantage patients. Our focus is on senior primary care, ensuring that older adults receive the time, respect, and specialized attention they deserve.
Each CenterWell location is staffed by a cross-disciplinary Care Team, including doctors, care coaches, behavioral health specialists, clinical pharmacists, and other professionals who deliver round-the-clock, patient-centered care.
Our facilities are designed specifically for seniors, offering:
✔ Longer appointments
✔ Shorter wait times
✔ Specialized exam rooms
✔ On-site specialists and pharmacy services
Beyond medical care, we prioritize social and physical well-being through on-site activity centers, providing seniors with opportunities to stay engaged and active—because research proves that staying connected is essential to healthy aging.
Through our team-based, whole-person approach, we help seniors navigate challenges such as depression, loneliness, housing insecurity, and chronic health conditions. By treating each patient as a complete individual, CenterWell fosters positive health outcomes and improved quality of life.
If you’re a Medicare Advantage recipient, we welcome you to take an active role in your health journey—with the dedicated support of CenterWell.
Job Responsibilities
✔ Assess Patient Needs – Develop a holistic understanding of patient needs related to Social Determinants of Health (SDOH).
✔ Identify Barriers – Recognize challenges preventing patients from accessing necessary resources and support.
✔ Health Education – Provide guidance on chronic condition management and inform patients about behavioral care and social support options.
✔ Patient Advocacy & Navigation – Act as a liaison between patients and healthcare providers, assisting with system navigation both internally and externally.
✔ Care Planning & Coordination – Develop care plans for high-risk patients, collaborating with an interdisciplinary team to implement action steps.
✔ Motivational Support – Empower patients to achieve their personal health goals through encouragement and self-determination.
✔ Transitions of Care – Facilitate smooth transitions for patients following hospital observation stays.
✔ Referral Services – Connect patients with essential services, such as:
- Transportation assistance
- Food insecurity support
- Medicaid applications and HCBS services
- Prescription cost reduction
- Follow-up appointment scheduling
- Social engagement opportunities
✔ Additional Duties – Perform all other responsibilities as required.
Organizational Responsibilities
✔ Complex Patient Coordination – Participate in interdisciplinary team discussions to ensure coordinated care.
✔ Confidentiality Compliance – Maintain patient privacy in accordance with HIPAA regulations.
✔ Accurate Documentation – Record patient encounters in the medical system promptly.
✔ Policy Adherence – Follow general safety, infection control, and attendance policies.
Required Qualifications
✔ Community Health Worker (CHW) certification in Texas
✔ Minimum of 2 years of experience in human services and community-based resource navigation
✔ Ability to travel between facilities in McAllen, Brownsville, Harlingen, and Edinburg, as well as to patient homes
Preferred Qualifications
✔ Bachelor’s degree in a related field
✔ Familiarity with state Medicaid guidelines and application processes
✔ Experience working with senior patients with complex healthcare needs
✔ Previous home visit experience and knowledge of field safety protocols
✔ Strongly Preferred: Bilingual (English/Spanish) with the ability to speak, read, and write fluently
Skills & Competencies
✔ Ability to multi-task in a fast-paced environment
✔ Flexibility to adapt to an evolving role
✔ Strong organizational skills and attention to detail
✔ Excellent communication skills (verbal and written)
✔ Exceptional interpersonal and relationship-building abilities
✔ Compassionate approach with a commitment to patient advocacy
✔ Critical thinking and problem-solving capabilities
Join us and make a meaningful impact by advocating for patients, removing barriers to care, and improving health outcomes in our communities!