Care Specialist Community Health Worker

7 months ago

The Bronx, United States Upward Health Full time

CARE SPECIALIST

Are you a dedicated individual with a passion for providing quality care and making a positive impact in the lives of others? If you possess a unique blend of skills and attributes, including critical thinking, resilience, and the ability to thrive in unstructured environments, we invite you to consider joining our team as a Care Specialist.

As a Care Specialist, you will play a crucial 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.

Your role will require you to be a self-starter, someone who not only understands the art of prioritization but is also keen to understand the "why" behind what we do. You'll engage with individuals from diverse backgrounds and often with complex needs, so the ability to work with difficult people and always be willing to help is a must. You don't just say "no"; you ask "how" and seek the "why."

Your awareness of community and diversity will be vital in ensuring that you provide culturally sensitive and inclusive care. Organizational skills, responsiveness, and flexibility are key as you navigate the ever-evolving landscape of healthcare.

Your self-motivation and ability to pivot, serving as a change agent when necessary, will be highly valued. You have an outcome-oriented approach and are willing to learn, adapting to new challenges and opportunities with enthusiasm.

Criticism doesn't deter you; you take it as a chance for self-improvement and growth. Self-awareness is your ally, and you thrive as an independent problem solver. Your passion for people is the driving force behind your commitment to delivering high-quality care.

If you possess these qualities and are ready to embrace a role that demands dedication, adaptability, and a deep desire to make a positive impact, we encourage you to explore the possibilities of becoming a Care Specialist within our organization. Join us in our mission to provide exceptional care and support to those who need it most.

Who is Upward Health

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 providers, 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

What you will do.

The Care Specialist works in patient’s homes and community 90% of the time and virtually the other 10% to deliver chronic care management to high complexity patients. During initial outreach the Care Specialist informs patients about our services and helps them get enrolled. Reaching out via phone is our top strategy for outreach and it’s important that the Care Specialist is comfortable and confident communicating by phone. Field-based approaches are utilized as well, and the Care Specialist should be prepared to use whatever strategy is most effective. Once the patient is enrolled, the Care Specialist will facilitate virtual visits from the patient’s home to our providers remotely to support our integrated care delivery model, focused on the following goals: Promote timely access to appropriate care; increase utilization of preventative care; reduce emergency room utilization and hospital readmissions; create and promote adherence to a care plan developed in coordination with the patient, primary care provider, and family/caregiver(s); increase patient’s ability for self-management and shared decision-making; provide medication reconciliation; connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costs

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.  Meets 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 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. 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 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. Prepares reports and documents as needed or requested. Attends regular daily huddle, team meetings and participates in clinical rounds. Other duties as needed. 

KNOWLEDGE, SKILLS & ABILITIES:

Strong critical thinking skills for assessing patient needs and treatment goals. Self-starter with the ability to work independently in an unstructured environment. Interpersonal savvy, demonstrated by the ability to interact with and influence people to establish trust and build strong relationships. Familiar with concepts like Motivational interviewing, trauma informed care and care coordination. Ability to complete unscheduled home visits, completed cold-calls and outreach. Strong organization skills and ability to manage and maintain a personal schedule. Proficient in time management and the ability to prioritize tasks effectively.  Ability to work independently within a field-based environment and as part of a team. Excellent communication and motivational interviewing skills to engage with difficult patients and the ability to explain technical medical information.  Proficient in the accurate and timely documentation of patient information in multiple electronic medical record (EMR) systems to ensure seamless continuity of care and data integrity. 

QUALIFICATIONS:

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

  • Medical Care Specialist

    4 weeks ago

    Bronx, United States Bronx Community Health Network Full time

    About Us: Bronx Community Health Network (BCHN) is a not-for-profit, community-based organization and Federally Qualified Health Center. Our mission is to improve the health of people and families in the Bronx by providing access to affordable, quality health care, especially for uninsured persons. We promote disease prevention, early treatment and healthful...

  • Community Care Specialist

    4 weeks ago

    Bronx, New York, United States Vocational Instruction Project Community Services Full time

    About UsVocational Instruction Project Community Services is a dedicated organization that aims to change lives and transform our community. We offer a continuum of services to individuals with histories of chemical dependency, empowering them to take charge of their lives and discover their personal paths to self-sufficiency.Our MissionWe are committed to...

  • Home Health Care Specialist

    18 hours ago

    Bronx, New York, United States BAYADA Home Health Care Full time

    BAYADA Home Health Care is a leading provider of home health care services, and we're seeking a dedicated and compassionate Home Health Care Specialist to join our team. As a Home Health Care Specialist, you'll have the opportunity to make a meaningful difference in the lives of our clients and their families.Job OverviewWe offer a variety of shift options,...

  • • Social Workers

    7 months ago

    The Bronx, United States BronxCare Health System Full time

    Social WorkersBronxCare Health System now has important opportunities at the outpatient and inpatient levels in its Department of Social Work. At BronxCare, Social Workers lead, learn, and educate, as well as collaborate across the full spectrum of key areas, providing discharge planning, transition of care, and education. Outpatient Social Workers (two...

  • Healthcare Professional for Underserved Communities

    4 weeks ago

    Bronx, New York, United States Bronx Community Health Network Full time

    We are actively seeking a Family Medicine Physician to join our Bronx Community Health Network Health Center.This is an extraordinary opportunity to practice patient care and become part of our team of dedicated health workers in the Bronx, one of New York City's most socio-economically depressed and medically underserved areas.Bronx Community Health Network...

  • Mental Health Nurse Specialist

    4 weeks ago

    Bronx, United States Institute for Community Living Full time

    Job Summary:Institute for Community Living seeks a skilled Registered Nurse to join our team as a Mental Health Nurse Specialist. This is an exciting opportunity to work in a dynamic environment, providing exceptional care to individuals with mental disabilities.About the Role:We are seeking a compassionate and experienced RN to provide direct patient care,...

  • Community Support Worker

    4 hours ago

    Bronx, New York, United States CENTER FOR URBAN COMMUNITY SVC Full time

    Housing Support ServicesThe Center for Urban Community Services is seeking a skilled Community Support Worker to join our team. In this role, you will provide vital support services to individuals and families struggling to maintain stable housing. Your primary responsibility will be to work closely with clients to help them navigate the complexities of the...

  • Primary Care Physician for Underserved Communities

    3 weeks ago

    Bronx, United States Bronx Community Health Network Full time

    We are seeking a dedicated Family Medicine Physician to join our team at Bronx Community Health Network (BCHN), a not-for-profit, community-based organization and Federally Qualified Health Center. Our mission is to improve the health of people and families in the Bronx by providing access to affordable, quality healthcare, especially for uninsured...

  • Community Health Specialist

    2 weeks ago

    Bronx, United States Center for Alternative Sentencing and Employment Services Full time

    Job Description: We are seeking a skilled Community Health Specialist to join our YA ACT team. The ideal candidate will have at least three years of experience working with young adults in psychiatric nursing or social service settings, with a strong understanding of community treatment, support services, and resources. Key responsibilities include:*...

  • Home Health Nurse with Excellent Communication Skills

    4 weeks ago

    The Bronx, United States Split Rock Rehabilitation and Health Care Center Full time

    About the RoleWe are seeking a dedicated and bilingual Home Health Nurse to join our team at Split Rock Rehabilitation and Health Care Center. As a Home Health Nurse, you will play a vital role in providing high-quality patient care in their homes.Job SummaryThe successful candidate will be responsible for admitting and reassessing home health patients,...

  • Community Liaison

    5 months ago

    The Bronx, United States SBH Health System Full time

    Job DescriptionPromotes a safe, cooperative and professional health care environment to ensure optimum patient care (as per HR policy 113c)Adheres to all hospital policies, procedures, rules and regulations, including but not limited to, absenteeism, cellular telephone usage, dress code and rules of conductProvide Excellent Customer Service, treating...

  • Home Health Care Specialist

    2 days ago

    Bronx, New York, United States Attending Home Care Services Full time

    Home Health Care SpecialistWe are seeking a compassionate and dedicated individual to join our team as a Home Health Care Specialist in Bronx, NY. This rewarding career offers a chance to make a positive impact on the lives of others.About Us:Attending Home Care Services is a growing home care provider committed to delivering exceptional care to our clients...

  • Dialysis Social Worker Position

    5 days ago

    Bronx, New York, United States Centers Health Care Full time

    Centers Health Dialysis is a leading provider of outpatient dialysis services, offering a unique opportunity for experienced Social Workers to join our team in the Bronx, NY area. In this role, you will play a vital part in delivering high-quality patient care and making a meaningful impact on patients' lives.We seek a licensed professional with a Master's...

  • Community Nursing Specialist

    3 weeks ago

    Bronx, New York, United States VNS Health Full time

    VNS Health Home Care is committed to providing exceptional patient care in the comfort of patients' homes. As a Community Nursing Specialist, you will play a vital role in delivering high-quality clinical outcomes and empowering patients to take control of their health.About the OpportunityThis per diem opportunity offers a unique chance to advance your...

  • Mental Health Care Specialist

    4 weeks ago

    Bronx, United States Essen Health Care Full time

    Company OverviewEsen Health Care is a growing community healthcare network that provides high-quality medical care to vulnerable residents in New York State.With a population health model of care, Esen has five integrated clinical divisions offering services in primary and specialty offices, urgent care centers, nursing homes, and via telehealth. Our Care...

  • Nursing Care Specialist

    2 weeks ago

    Bronx, New York, United States Maximus Full time

    Role Overview:We are seeking a skilled and compassionate Nursing Care Specialist to join our team in Bronx, New York. As a key member of our community health team, you will be responsible for conducting thorough assessments of patients in their homes, ensuring they receive the necessary care and support.About the Role:Conduct comprehensive home assessments...

  • Physician - Primary Care Specialist

    4 weeks ago

    Bronx, United States Essen Health Care Full time

    Job DescriptionWe are seeking a skilled Physician to join our team at Essen Health Care. As a Primary Care Specialist, you will be responsible for providing high-quality medical care to patients in our nursing home division.About UsEssen Health Care is a growing community healthcare network that provides compassionate and accessible medical care to...

  • Social Worker

    7 months ago

    The Bronx, United States Tolentine Zeiser Community Life Center Full time $49,740

    Responsibilities: Supervise Case Managers and Housing Specialists Staff to ensure delivery of services to families residing in the facility as outlined in the house rules, NYC/DHS and NYSOTDA regulations.Provide direct Supervision to subordinate staff with opportunity for professional growth training to ensure that development and maintenance of skills do...

  • Podiatric Medicine Physician

    3 weeks ago

    The Bronx, United States Bronx Community Health Network Full time

    We are actively seeking a Podiatrist (part-time) to join our Health Center in White Plains Road, Bronx.This is an extraordinary opportunity to practice patient care and become part of our amazing team of dedicated health workers!Bronx Community Health Network (BCHN) was founded in 1996 to ensure that the socio-economically depressed and medically underserved...

  • Internal Medicine Physician

    2 weeks ago

    The Bronx, United States Bronx Community Health Network Full time

    We are actively seeking a Family Medicine Physician to join our new FQHC Health Center in 3763 White Plains Road, Bronx, NY, 10467 opening February 2025.This is an extraordinary opportunity to practice patient care and become part of our amazing team of dedicated health workers! Bronx Community Health Network (BCHN) was founded in 1996 to ensure that the...