Description: Care Specialist
Upward Health is a home-based medical group specializing in primary medical and behavioral care for individuals with complex needs. We serve patients throughout their communities, and we diagnose, treat, and prescribe anywhere our patients call home. We reduce barriers to care such as long delays due to scheduling. We see patients when they need us, for as much time as they need, bringing care to them. Beyond medical supports, we also assist our patients with challenges that may affect their health, such as food insecurity, social isolation, housing needs, transportation and more. It's no wonder 98% of patients report being fully satisfied with Upward Health!
Upward Health provides technology-enabled, integrated, and coordinated care delivery services that improve outcomes and reduce costs for patients with severe behavioral health diagnoses and co-morbid, chronic physical conditions. We are not your typical medical practice. At Upward Health, we see every day as an opportunity to make a difference in our patients' lives. We could tell you about our outcomes and patient satisfaction ratings. We could tell you about our commitment to our mission. Or, you could join us and experience it all for yourself.
The Care Team is a multidisciplinary team of licensed and unlicensed staff who provide direct support and care to Upward Health's patients. The Care Team is comprised of a diverse team that may include registered nurses, licensed social workers, pharmacists, therapists and paramedics, care navigators and care specialists. This team works within the community and in the patients' homes or meet in agreed upon locations in the community. Why Is This Role Critical?
The Care Specialist works in patient's homes and virtually to deliver chronic care management to high complexity patients. This position is the first point of contact with our company for our patients. We count on the Care Specialist to make an excellent first impression and to be able to effectively communicate our service offering to 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
Requirements: KEY RESPONSIBILITIES:
KNOWLEDGE, SKILLS & ABILITIES:
- Conduct direct outreach to patients via phone, in-person meetings, mailings, and other strategies
- Speak with patients about the role that Upward Health can play in helping them improve their health
- Enroll patients into Upward Health's program and collect key data about patients during the enrollment process
- Capture accurate and timely documentation in our company's software system
- Care Delivery
- Meets patients in their home or in the community to conduct a needs assessment, including helping patients to set health goals
- Facilitate appointments between patients and care team as needed
- Record vital statistics and other health information in electronic medical record (EMR)
- Monitor patients to detect health problems.
- 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 patients.
- Collect medical information from patients, family members, or other medical professionals.
- Administer basic health care or medical treatments as directed by Upward Health care providers
- Operate medical equipment (glucometer, electronic devices for V.S. monitoring)
- 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 patient calls for initial care plans, follow-up with patients, family/caregiver(s), providers, and community resources via secure e-mail, phone calls, and other communications
- Facilitate patient access to appropriate medical and specialty providers
- Strong organizational skills to assist patients coordinating services across providers
- Makes follow-up calls and home visits to patients per Upward Health policy
- Coordinates with Clinical Care team
- Documents each patient encounter in detail per Upward Health Policies
- Prepares reports and documents as needed or requested
- Attends regular team meetings and participate in clinical rounds
- Performs other duties as assigned
- Interpersonal savvy, demonstrated by the ability to interact with and influence people to establish trust and build strong relationships
- Ability to do home visits and outreach
- Experience with usage of EMR/EHRs
- Experience working in a high-volume physician practice, hospital setting, or possibly a home care role.
- Strong organization skills and ability to manage and maintain a personal schedule
- Ability to establish priorities and meet deadlines
- Ability to work independently within a virtual operating environment and as part of a team
- Excellent oral and written communication skills
- Ability to exercise judgment in the application of professional services
- Active listening skills and genuine compassion for others
- Enjoys collaboration within a team environment and working with people of different skills and experience
- Knowledge of community resources in the local market
- Able to maintain clear professional boundaries with patients and coworkers
- Commitment to represent the company with professionalism
- Demonstrates cultural competency and ability to work with diverse groups of community members
- Comfortable using computer for documentation, communication, and organizing work
- At least 3 years of relevant work experience
- High school graduate or GED required
- 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
- Must have reliable transportation with a valid driver's license and auto liability insurance
- Ability to complete Upward Health's initial training program and ongoing educational requirements as assigned
- Ability to work flexible hours, including occasional night/weekend work
- Multi-lingual capabilities preferred, but not required
- Prior experience as a Community Health Worker, Peer Support Specialist, Medical Assistant or similar role a plus
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. All individuals selected for a position will undergo a background check appropriate for the position's responsibilities. We require all our employees to be vaccinated and to show proof of vaccination upon hire PM22