Care Specialist - Enhanced Care Management

Care Specialist - Enhanced Care Management at Upward Health summary:

Field-based Care Specialist providing enhanced care management for high-complexity patients through home visits, phone outreach, and community engagement to coordinate chronic and behavioral health services. Responsibilities include assessing needs, setting health goals, facilitating access to resources, documenting in EMRs, and reducing acute care utilization. Requires experience in care coordination or community health work, a driver’s license and reliable transportation, strong communication/motivational interviewing skills, and ability to work independently in the community.

Company Overview:

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 - ECM is responsible for coordinating care for high-complexity patients, mainly working in the field to provide chronic care coordination and support. This role involves direct outreach to patients through phone calls, home visits, and community interactions. The Care Specialist primarily works in patients' homes and communities (90% of the time) and engages in virtual or telephonic support (10% of the time) The Care Specialist will assess patient needs, help set health goals, and ensure that patients receive the appropriate care and resources, with a focus on increasing access to preventative care, reducing emergency room visits, and enhancing self-management.

The role requires excellent communication skills, critical thinking, and the ability to work independently and adapt to evolving challenges.

Skills Required:

• At least 2 years of relevant work experience as a Community Health Worker, Peer Support Specialist, Medical Assistant, or in a similar role.
• High school diploma or GED required.
• A valid driver’s license and auto liability insurance.
• Reliable transportation and the ability to travel within assigned territory or as needed.
• Experience in care coordination for individuals with chronic conditions, behavioral health conditions, or with patients experiencing housing insecurities including homelessness.
• Strong interpersonal and motivational interviewing skills to build trust and rapport with patients.
• Familiarity with trauma-informed care, care coordination, and patient education.
• Proficiency in the use of electronic medical records (EMR) systems and basic computer skills.
• Technologically savvy and able to manage documentation and data entry effectively.
• Ability to work independently in a field-based environment and as part of a team.
• Multi-lingual capabilities preferred but not required.
• Prior home care or Enhanced Care Management experience a plus.
• Community Health Worker certification is a plus.

Key Behaviors:

Adaptability:

• Ability to work in dynamic, unstructured environments, pivoting quickly to meet the needs of patients and the organization.

Critical Thinking & Problem Solving:

• Demonstrates strong problem-solving skills when assessing patient needs and determining the best course of action.

Motivational Interviewing & Empathy:

• Uses motivational interviewing techniques to build rapport, set health goals, and empower patients to take charge of their care.

Relationship Building:

• Skilled in establishing trust and fostering strong relationships with patients, families, and team members.

Self-Starter:

• Takes initiative to perform outreach, complete assessments, and follow through with care coordination independently.

Organizational

Skills:

• Excellent at managing time, tasks, and schedules, ensuring that all patient needs are…