Job Description

CARE SPECIALIST - ECM

Are you a dedicated individual with a passion for providing quality care and making a positive impact in the lives of others? If you possess a unique blend of skills and attributes, including critical thinking, resilience, and the ability to thrive in unstructured environments, we invite you to consider joining our team as a Care Specialist.

As a Care Specialist, you will play a crucial role in our organization, working in a dynamic and ever-changing field. Your responsibilities will extend beyond the ordinary, and we are looking for someone who possesses the tenacity, resilience, and perseverance to excel in challenging situations.

Your role will require you to be a self-starter, someone who not only understands the art of prioritization but is also keen to understand the "why" behind what we do. You'll engage with individuals from diverse backgrounds and often with complex needs, so the ability to work with difficult people and always be willing to help is a must. You don't just say "no"; you ask "how" and seek the "why

Your awareness of community and diversity will be vital in ensuring that you provide culturally sensitive and inclusive care. Organizational skills, responsiveness, and flexibility are key as you navigate the ever-evolving landscape of healthcare.

Your self-motivation and ability to pivot, serving as a change agent when necessary, will be highly valued. You have an outcome-oriented approach and are willing to learn, adapting to new challenges and opportunities with enthusiasm.

Criticism doesn't deter you; you take it as a chance for self-improvement and growth. Self-awareness is your ally, and you thrive as an independent problem solver. Your passion for people is the driving force behind your commitment to delivering high-quality care.

If you possess these qualities and are ready to embrace a role that demands dedication, adaptability, and a deep desire to make a positive impact, we encourage you to explore the possibilities of becoming a Care Specialist within our organization. Join us in our mission to provide exceptional care and support to those who need it most.

Who is Upward Health

Upward Health is an in-home, multidisciplinary medical group providing 24/7 whole-person care. Our clinical team treats physical, behavioral, and social health needs when and where a patient needs help. Everyone on our team from our providers, nurses, and Care Specialists to our HR, Technology, and Business Services staff are driven by a desire to improve the lives of our patients. We are able to treat a wide range of needs – everything from addressing poorly controlled blood sugar to combatting anxiety to accessing medically tailored meals – because we know that health requires care for the whole person. It’s no wonder 98% of patients report being fully satisfied with Upward Health!

What you will do.

The Care Specialist works in patient’s homes and community 90% of the time and virtually the other 10% to deliver chronic care management to high complexity patients. During initial outreach the Care Specialist informs patients about our services and helps them get enrolled.  Reaching out via phone is our top strategy for outreach and it’s important that the Care Specialist is comfortable and confident communicating by phone.  Field-based approaches are utilized as well, and the Care Specialist should be prepared to use whatever strategy is most effective.   Once the patient is enrolled, the Care Specialist will coordinate care from the patient’s home or the community to support our integrated care delivery model, focused on the following goals: Promote timely access to appropriate care; increase utilization of preventative care; reduce emergency room utilization and hospital readmissions; create and promote adherence to a care plan developed in coordination with the patient, primary care provider, and family/caregiver(s); increase patient’s ability for self-management and shared decision-making; provide medication reconciliation; connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costs

KEY RESPONSIBILITIES:

• 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.
• Coordinate care between patients and interdisciplinary care teams as needed. 
• 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. 
• 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. 

KNOWLEDGE, SKILLS & ABILITIES:

• 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. 

QUALIFICATIONS:

• 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 is proud to be an equal opportunity/affirmative action employer. We are committed to attracting, retaining, and maximizing the performance of a diverse and inclusive workforce. 

This job description is a general outline of duties performed and is not to be misconstrued as encompassing all duties performed within the position.