Care Specialist

• Conduct direct outreach to patients via phone, in-person, mailings, and other strategies including cold calling and unscheduled door knocks.
• Enroll patients into Upward Health’s program and collect key data about patients during the enrollment process through continuous and on-going phone and in-person interactions.
• Meets patients in their home or in the community to conduct a needs assessment, including helping patients to set health goals.
• Facilitate in-home provider appointments and coordinate care between patients and care team as needed. Ensuring that all of your assigned patients have an initial provider visit and follow up visits scheduled.
• Support your patients in meeting their healthcare goals as it relates to Quality measures.
• Work within an interdisciplinary team to support the team’s effort in meeting market and/or organizational goals.
• Obtain and record vital signs and other health information in electronic medical record (EMR)
• Analyze patient data to determine patient needs or treatment goals.
• Assess physical conditions of patients to aid in diagnosis, treatment; and/or need for additional referrals in support of health and social needs.
• Explain technical medical information to educate the patients.
• Cultivate and support the primary care providers with timely communication, inquiry follow-up, and integration of information into the care plan regarding transitions-in-care and referral.
• Builds rapport with Upward Health patients utilizing motivational interviewing techniques.
• Conduct one-on-one extended in-person patient appointments.
• Makes follow-up calls and home visits to patients per Upward Health policy.
• Documents each patient encounter with accuracy and precision.
• Prepares reports and documents as needed or requested.
• Attends regular daily huddle, team meetings and participates in clinical rounds.
• Other duties as needed.

• Strong critical thinking skills for assessing patient needs and treatment goals.
• Self-starter with the ability to work independently in an unstructured environment.
• Interpersonal savvy, demonstrated by the ability to interact with and influence people to establish trust and build strong relationships.
• Familiar with concepts like Motivational interviewing, trauma informed care and care coordination.
• Ability to complete unscheduled home visits, completed cold-calls and outreach.
• Strong organization skills and ability to manage and maintain a personal schedule.
• Proficient in time management and the ability to prioritize tasks effectively.
• Ability to work independently within a field-based environment and as part of a team.
• Excellent communication and motivational interviewing skills to engage with difficult patients and the ability to explain technical medical information.
• Proficient in the accurate and timely documentation of patient information in multiple electronic medical record (EMR) systems to ensure seamless continuity of care and data integrity.

• At least 2 years of relevant work experience as a Community Health Worker, Peer Support Specialist, Medical Assistant, or similar role
• High school graduate or GED required.
• A valid driver’s license and auto liability insurance.
• Reliable transportation and the ability to travel within your assigned territory or other as needed to support the patient needs plan and training requirements.
• Experience in Chronic Care Management model OR experience with chronically ill/elderly patients.
• Long-time resident of the community with good knowledge of the resources of this community.
• Ability to complete Upward Health’s initial training program and ongoing educational requirements as assigned, both virtually and in-person.
• Technologically savvy with basic computer skills, including ability to type.
• Multi-lingual capabilities preferred, but not required.
• Prior Home Care experience a plus

Upward Health