Care Specialist

3 weeks ago

Phoenix, Arizona, United States Upward Health Full time
About Upward Health

Upward Health is a leading provider of in-home, multidisciplinary medical care, delivering 24/7 whole-person care to patients in need. Our clinical team treats physical, behavioral, and social health needs, addressing the complexities of modern healthcare.

Job Summary

We are seeking a highly skilled Care Specialist to join our team, working in patient's homes and community to deliver chronic care management to high complexity patients. As a Care Specialist, you will play a vital role in our organization, working in a dynamic and ever-changing field. Your responsibilities will extend beyond the ordinary, and we are looking for someone who possesses the tenacity, resilience, and perseverance to excel in challenging situations.

Key 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 during the enrollment process.
  • Meet patients in their home or in the community to conduct a needs assessment, including helping patients to set health goals.
  • Facilitate in-home provider appointments and coordinate care between patients and care team as needed, ensuring that all assigned patients have an initial provider visit and follow-up visits scheduled.
  • 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.
  • Obtain and record vital signs and other health information in electronic medical record (EMR).
  • 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.
  • Other duties as needed.
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 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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