Care Specialist - Justice-Involved ECM

Company Overview:

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 doctors, 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!

Job Title & Role Description:

The Care Specialist - ECM is responsible for coordinating care for high-complexity patients, mainly working in the field to provide chronic care coordination and support. This role involves direct outreach to patients through phone calls, home visits, and community interactions. The Care Specialist primarily works in patients' homes and communities (90% of the time) and engages in virtual or telephonic support (10% of the time) The Care Specialist will assess patient needs, help set health goals, and ensure that patients receive the appropriate care and resources, with a focus on increasing access to preventative care, reducing emergency room visits, and enhancing self-management. The role requires excellent communication skills, critical thinking, and the ability to work independently and adapt to evolving challenges.

Skills Required:

• At least 2 years of relevant work experience as a Community Health Worker, Peer Support Specialist, Medical Assistant, or in a similar role.
• High school diploma or GED required.
• A valid driver’s license and auto liability insurance.
• Reliable transportation and the ability to travel within assigned territory or as needed.
• Experience in care coordination for individuals with chronic conditions, behavioral health conditions, or with patients experiencing housing insecurities including homelessness.
• Strong interpersonal and motivational interviewing skills to build trust and rapport with patients.
• Familiarity with trauma-informed care, care coordination, and patient education.
• Proficiency in the use of electronic medical records (EMR) systems and basic computer skills.
• Technologically savvy and able to manage documentation and data entry effectively.
• Ability to work independently in a field-based environment and as part of a team.
• Multi-lingual capabilities preferred but not required.
• Prior home care or Enhanced Care Management experience a plus.
• Community Health Worker certification is a plus.

Key Behaviors:

Adaptability:

• Ability to work in dynamic, unstructured environments, pivoting quickly to meet the needs of patients and the organization.

Critical Thinking & Problem Solving:

• Demonstrates strong problem-solving skills when assessing patient needs and determining the best course of action.

Motivational Interviewing & Empathy:

• Uses motivational interviewing techniques to build rapport, set health goals, and empower patients to take charge of their care.

Relationship Building:

• Skilled in establishing trust and fostering strong relationships with patients, families, and team members.

Self-Starter:

• Takes initiative to perform outreach, complete assessments, and follow through with care coordination independently.

Organizational Skills:

• Excellent at managing time, tasks, and schedules, ensuring that all patient needs are addressed in a timely manner.

Resilience:

• Demonstrates resilience in challenging situations and remains focused on the goal of improving patient outcomes despite setbacks.

Cultural Competence:

• Demonstrates sensitivity to and understanding of diverse cultural backgrounds, ensuring that care is provided in a culturally inclusive manner.

Commitment to Quality Care:

• Shows passion for delivering high-quality care and support to patients, ensuring their well-being and satisfaction.

Competencies:

Care Coordination:

• Ability to assess patient needs, coordinate care with interdisciplinary teams, and ensure patients are receiving the appropriate services.

Patient Advocacy:

• Supports patients by navigating healthcare systems, advocating for needed resources, and ensuring timely access to care.

Health Education & Communication:

• Educates patients about their health conditions, treatments, and the healthcare system in a clear and empathetic manner.

Data Management & Reporting:

• Proficient in documenting patient interactions and maintaining accurate, up-to-date records in EMR systems.

Patient Outreach & Engagement:

• Proactively reaches out to patients through multiple communication channels, including phone, in-person visits, and community outreach.

Goal Setting & Self-Management:

• Works with patients to develop self-care plans, emphasizing shared decision-making and increasing the patient’s ability to manage their own health.

Collaboration & Teamwork:

• Works effectively as part of an interdisciplinary care team to achieve organizational goals and improve patient outcomes.

Crisis Management & Flexibility:

• Demonstrates flexibility and adaptability in managing unforeseen challenges, providing support where it is needed most.

Technical Proficiency:

• Skilled in using healthcare software applications and systems for accurate data entry and patient management.

Upward Health is proud to be an equal opportunity employer. We are committed to attracting, retaining, and maximizing the performance of a diverse and inclusive workforce. This job description is a general outline of duties performed and is not to be misconstrued as encompassing all duties performed within the position.