Job Description

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 doctors, 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!

Job Title & Role Description:

The Care Specialist is a key member of the team responsible for delivering chronic care management to high-complexity patients. The Care Specialist primarily works in patients' homes and communities (90% of the time) and engages in virtual care (10% of the time). This role involves direct outreach to patients, guiding them through the enrollment process, facilitating virtual appointments with providers, and ensuring that patients adhere to care plans. By building relationships, coordinating care, and providing education, the Care Specialist plays a critical role in promoting health, preventing unnecessary hospitalizations, and improving patient outcomes.

Skills Required:

• Minimum of 2 years of relevant work experience (e.g., Community Health Worker, Peer Support Specialist, Medical Assistant, etc.).
• High school diploma or GED required.
• A valid driver’s license, auto liability insurance, and reliable transportation to travel within the assigned territory.
• Experience in chronic care management or working with chronically ill/elderly patients.
• Technologically proficient with basic computer skills (typing, using EMR systems).
• Experience with motivational interviewing, trauma-informed care, and care coordination.
• Strong interpersonal communication skills with the ability to engage patients and team members effectively.
• Ability to prioritize tasks, manage schedules, and work independently in an unstructured environment.
• Multi-lingual skills are a plus but not required.
• Prior home care experience is beneficial.

Key Behaviors:

Adaptability & Resilience:

• Ability to thrive in unstructured environments and pivot as needed to meet patient needs. Demonstrates perseverance in challenging situations.

Self-Starter & Motivation:

• Proactively takes initiative in managing patient care and outreach. Willingness to learn and adapt to new processes and systems.

Empathy & Compassion:

• Ability to work with individuals from diverse backgrounds and understand their complex needs. Skilled in building rapport through motivational interviewing and other patient-centered communication techniques.

Accountability & Integrity:

• Demonstrates personal responsibility and takes ownership of tasks, ensuring accuracy and timeliness in all activities.

Cultural Competence:

• Awareness of community dynamics and diversity, ensuring culturally sensitive and inclusive care.

Team Collaboration:

• Works collaboratively with interdisciplinary teams to meet patient and organizational goals.

Problem-Solving & Critical Thinking:

• Strong critical thinking skills to assess patient needs, analyze data, and develop appropriate care strategies.

Communication Skills:

• Excellent verbal and written communication, capable of explaining complex medical information to patients in a clear and supportive manner.

Competencies:

Care Coordination:

• Ability to engage patients in a comprehensive care plan, facilitating communication between patients, providers, and family members to ensure timely, effective care.

Health Education:

• Effectively educates patients about their medical conditions, care plans, and available resources, ensuring that patients can make informed decisions.

Patient Engagement:

• Uses various strategies, including phone calls, home visits, and community outreach, to engage patients and ensure continuous participation in their care.

Time Management & Organization:

• Demonstrates strong organizational skills by managing patient caseloads, schedules, and documentation efficiently.

Technology Proficiency:

• Skilled in using electronic health records (EMR) systems and other digital tools to document patient information and communicate within the team.

Motivational Interviewing & Patient-Centered Care:

• Uses motivational interviewing techniques to build rapport and empower patients to take ownership of their health decisions.

Data Management:

• Ensures accurate and timely documentation of patient data, ensuring continuity of care and compliance with organizational standards.

Outcome-Oriented Approach:

• Focuses on achieving key health outcomes, such as improved care adherence, reduction in emergency room visits, and enhanced self-management.

Upward Health is proud to be an equal opportunity 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.

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