Care Specialist Community Health Worker
2 weeks ago
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.
Job SummaryWe are seeking a highly motivated and compassionate Care Specialist to join our team. As a Care Specialist, you will work in patients' homes and communities to deliver chronic care management to high-complexity patients. Your primary responsibility will be to facilitate virtual visits from patients' homes to our providers remotely, supporting our integrated care delivery model.
Key Responsibilities:- 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.
- Meet patients in their homes or in the community to conduct needs assessments, including helping patients set health goals.
- Facilitate in-home provider appointments and coordinate care between patients and the care team 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.
- Obtain and record vital signs and other health information in electronic medical records.
- 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.
- 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.
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.
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