Care Coordination Associate

Job Description

We are seeking a highly skilled and compassionate individual to join our team as a Care Specialist. As a Care Specialist, you will work closely with patients to develop personalized care plans that address their unique needs and circumstances.

Your responsibilities will include conducting outreach and enrollment activities, coordinating care between patients and interdisciplinary teams, and supporting patients in meeting their healthcare goals. You must be comfortable communicating by phone and able to interact with individuals from diverse backgrounds and with complex needs.

Responsibilities

• Conduct direct outreach to patients via phone, in-person, mailings, and other strategies to enroll patients into Upward Health's program and collect key data about patients.
• Meet 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.