Care Specialist

2 days ago

Monterey, California, United States Upward Health Full time
Care Specialist - ECM Job Description

Upward Health is seeking a dedicated Care Specialist - ECM to join our team. As a Care Specialist - ECM, you will play a crucial role in delivering high-quality care to our patients. Your primary responsibility will be to conduct direct outreach to patients via phone, in-person, mailings, and other strategies to enroll them into our program and collect key data about patients during the enrollment process.

Key Responsibilities:
  • Conduct direct outreach to patients via phone, in-person, mailings, and other strategies to enroll them into our program.
  • Collect key data about patients during the enrollment process through continuous and on-going phone and in-person interactions.
  • 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 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 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.
  • 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.
Requirements:
  • 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.

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