In-Home Chronic Care Manager

1 week ago

Lafayette, Louisiana, United States Upward Health Full time
About Upward Health
Upward Health is an in-home, multidisciplinary medical group that provides 24/7 whole-person care. Our clinical team treats physical, behavioral, and social health needs when and where patients need help.

Role Overview
We are seeking a highly motivated and compassionate In-Home Chronic Care Manager to join our team. As a member of our team, you will work closely with patients, families, and healthcare providers to deliver high-quality, patient-centered care in the comfort of their own homes. 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 through continuous and on-going phone and in-person interactions.

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 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.
  • Facilitate in-home provider appointments and coordinate care between patients and care team as needed.
  • Ensure that all of your assigned patients have an initial provider visit and follow up visits scheduled.
  • Support your 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.
  • Affect 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 the patients.
  • Cultivate and support the 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.

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