Care Specialist

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 this role as a Care Specialist.

The Care Specialist plays a crucial role in our organization, working in a dynamic and ever-changing field. Responsibilities extend beyond the ordinary, and we are looking for someone who possesses tenacity, resilience, and perseverance to excel in challenging situations.

Your role requires being a self-starter, someone who understands the art of prioritization and is 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 essential. You don't just say 'no'; you ask 'how' and seek the 'why'.

The awareness of community and diversity is 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.

Self-motivation and the 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 drives your commitment to delivering high-quality care.

About 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 patients need help. Everyone on our team, from providers and nurses to Care Specialists and staff, is driven by a desire to improve patient lives. We 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. Patients report being fully satisfied with Upward Health at a rate of 98%.

Job Summary

The Care Specialist works in patients' homes and communities 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. The top strategy for outreach is phone calls, but field-based approaches are also utilized. Once patients are enrolled, the Care Specialist coordinates care from their home or community to support our integrated care delivery model, focusing on timely access to appropriate care, increasing preventative care utilization, reducing emergency room utilization and hospital readmissions, and promoting adherence to a care plan developed in coordination with the patient, primary care provider, and family/caregiver(s).

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 ongoing phone and in-person interactions.
• Meet patients in their home or in the community to conduct a needs assessment, including helping patients set health goals.
• Coordinate care between patients and interdisciplinary care teams as needed.
• Support patients in meeting their healthcare goals related 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 patients.
• Cultivate and support primary care providers with timely communication, inquiry follow-up, and integration of information into the care plan regarding transitions-in-care and referral.
• Build rapport with Upward Health patients using motivational interviewing techniques.
• Conduct one-on-one extended in-person patient appointments.
• Make follow-up calls and home visits to patients per Upward Health policy.
• Document each patient encounter with accuracy and precision.
• Prepare reports and documents as needed or requested.
• Attend regular daily huddle, team meetings, and participate 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 explain technical medical information.
• Proficient in accurately and timely documenting 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 patient needs 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 resources.
• 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 typing.
• 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.