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 Nurse Practitioner (NP) is responsible for providing high-quality, patient-centered, comprehensive primary care. Utilizing Upward Health’s proprietary Facilitated Virtual Care platform, the NP delivers care that improves outcomes and reduces costs for patients with complex diagnoses and co-morbid, chronic conditions. This role primarily involves virtual patient care with periodic or as needed in-person care to support transitions of care, annual wellness visits, risk adjustments, primary care needs, and urgent visits. The NP collaborates closely with a multidisciplinary team to provide whole-person care to our patients in their homes.

Key Responsibilities:

• Triage, diagnose, and treat patients in person or via our virtual care platform.
• Serve as a day-to-day clinical leader, providing decision support and directing the multidisciplinary team under the guidance of the Medical Director.
• Conduct primary care, urgent visits, and annual wellness exams, ensuring all appropriate screening tests and quality measures are addressed.
• Refer patients appropriately for behavioral health and specialty services.
• Coordinate care transitions to prevent hospital readmissions by collaborating with PCPs, hospitalists, and SNF providers.
• Participate in the on-call provider schedule to support the 24/7 patient hotline, requiring after-hours and weekend availability on a rotating and recurring basis.
• Foster a collaborative working environment with all members of the interdisciplinary team, contributing to daily huddles, team meetings, and patient discussions.
• Monitor and respond to remote patient data collected through monitoring devices.
• Perform other duties as assigned.

Knowledge, Skills & Abilities:

• Perform and document accurate and thorough risk assessments for the purpose of accurate documentation of condition(s).
• Expertise in managing complex, polychronic patients, with demonstrated ability to assess and treat high-acuity patients.
• Familiarity with caring for Medicare and Medicaid populations, with experience in both inpatient and outpatient or home care settings.
• Proficiency in motivational interviewing, trauma-informed care, and supporting vulnerable populations is preferred.
• Excellent written, computer, and oral communication skills, with the ability to communicate efficiently and proactively with the clinical team.
• Dedication to health equity and transforming care for patients in their homes.
• Strong organizational skills and ability to provide clinical leadership and coordination.

Qualifications:

• Minimum of 5 years’ experience as a provider, with a minimum of 3 years in a primary care, or related, setting.
• Multi-state Advanced Nursing License or willingness to obtain.
• A valid driver’s license and auto liability insurance.
• Willingness and ability to travel as needed, though responsibilities are primarily performed virtually.
• Experience in urgent/emergent care settings is a plus.

Key Competencies:

Clinical Leadership:

• Ability to provide decision support and leadership to the care team.

Patient-Centered Care: 

• Focused on delivering high-quality, compassionate care to improve patient outcomes.

Collaboration: 

• Works effectively within a multidisciplinary team to provide comprehensive care

Adaptability: 

• Thrives in a dynamic, fast-paced environment with evolving protocols.

Problem-Solving: 

• Proactively identifies and addresses challenges in patient care and team coordination.

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.

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 Nurse Practitioner (NP) is responsible for providing high-quality, patient-centered, comprehensive primary care. Utilizing Upward Health’s proprietary Facilitated Virtual Care platform, the NP delivers care that improves outcomes and reduces costs for patients with complex diagnoses and co-morbid, chronic conditions. This role primarily involves virtual patient care with periodic or as needed in-person care to support transitions of care, annual wellness visits, risk adjustments, primary care needs, and urgent visits. The NP collaborates closely with a multidisciplinary team to provide whole-person care to our patients in their homes.

Key Responsibilities:

• Triage, diagnose, and treat patients in person or via our virtual care platform.
• Serve as a day-to-day clinical leader, providing decision support and directing the multidisciplinary team under the guidance of the Medical Director.
• Conduct primary care, urgent visits, and annual wellness exams, ensuring all appropriate screening tests and quality measures are addressed.
• Refer patients appropriately for behavioral health and specialty services.
• Coordinate care transitions to prevent hospital readmissions by collaborating with PCPs, hospitalists, and SNF providers.
• Participate in the on-call provider schedule to support the 24/7 patient hotline, requiring after-hours and weekend availability on a rotating and recurring basis.
• Foster a collaborative working environment with all members of the interdisciplinary team, contributing to daily huddles, team meetings, and patient discussions.
• Monitor and respond to remote patient data collected through monitoring devices.
• Perform other duties as assigned.

Knowledge, Skills & Abilities:

• Perform and document accurate and thorough risk assessments for the purpose of accurate documentation of condition(s).
• Expertise in managing complex, polychronic patients, with demonstrated ability to assess and treat high-acuity patients.
• Familiarity with caring for Medicare and Medicaid populations, with experience in both inpatient and outpatient or home care settings.
• Proficiency in motivational interviewing, trauma-informed care, and supporting vulnerable populations is preferred.
• Excellent written, computer, and oral communication skills, with the ability to communicate efficiently and proactively with the clinical team.
• Dedication to health equity and transforming care for patients in their homes.
• Strong organizational skills and ability to provide clinical leadership and coordination.

Qualifications:

• Minimum of 5 years’ experience as a provider, with a minimum of 3 years in a primary care, or related, setting.
• Multi-state Advanced Nursing License or willingness to obtain.
• A valid driver’s license and auto liability insurance.
• Willingness and ability to travel as needed, though responsibilities are primarily performed virtually.
• Experience in urgent/emergent care settings is a plus.

Key Competencies:

Clinical Leadership:

• Ability to provide decision support and leadership to the care team.

Patient-Centered Care: 

• Focused on delivering high-quality, compassionate care to improve patient outcomes.

Collaboration: 

• Works effectively within a multidisciplinary team to provide comprehensive care

Adaptability: 

• Thrives in a dynamic, fast-paced environment with evolving protocols.

Problem-Solving: 

• Proactively identifies and addresses challenges in patient care and team coordination.

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.

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 is a key member of the team responsible for delivering chronic care management to high-complexity patients. The Care Specialist primarily works in patients' homes and communities (90% of the time) and engages in virtual care (10% of the time). This role involves direct outreach to patients, guiding them through the enrollment process, facilitating virtual appointments with providers, and ensuring that patients adhere to care plans. By building relationships, coordinating care, and providing education, the Care Specialist plays a critical role in promoting health, preventing unnecessary hospitalizations, and improving patient outcomes.

Skills Required:

• Minimum of 2 years of relevant work experience (e.g., Community Health Worker, Peer Support Specialist, Medical Assistant, etc.).
• High school diploma or GED required.
• A valid driver’s license, auto liability insurance, and reliable transportation to travel within the assigned territory.
• Experience in chronic care management or working with chronically ill/elderly patients.
• Technologically proficient with basic computer skills (typing, using EMR systems).
• Experience with motivational interviewing, trauma-informed care, and care coordination.
• Strong interpersonal communication skills with the ability to engage patients and team members effectively.
• Ability to prioritize tasks, manage schedules, and work independently in an unstructured environment.
• Multi-lingual skills are a plus but not required.
• Prior home care experience is beneficial.

Key Behaviors:

Adaptability & Resilience: 

• Ability to thrive in unstructured environments and pivot as needed to meet patient needs. Demonstrates perseverance in challenging situations.

Self-Starter & Motivation: 

• Proactively takes initiative in managing patient care and outreach. Willingness to learn and adapt to new processes and systems.

Empathy & Compassion: 

• Ability to work with individuals from diverse backgrounds and understand their complex needs. Skilled in building rapport through motivational interviewing and other patient-centered communication techniques.

Accountability & Integrity: 

• Demonstrates personal responsibility and takes ownership of tasks, ensuring accuracy and timeliness in all activities.

Cultural Competence: 

• Awareness of community dynamics and diversity, ensuring culturally sensitive and inclusive care.

Team Collaboration: 

• Works collaboratively with interdisciplinary teams to meet patient and organizational goals.

Problem-Solving & Critical Thinking: 

• Strong critical thinking skills to assess patient needs, analyze data, and develop appropriate care strategies.

Communication Skills: 

• Excellent verbal and written communication, capable of explaining complex medical information to patients in a clear and supportive manner.

Competencies:

Care Coordination: 

• Ability to engage patients in a comprehensive care plan, facilitating communication between patients, providers, and family members to ensure timely, effective care.

Health Education: 

• Effectively educates patients about their medical conditions, care plans, and available resources, ensuring that patients can make informed decisions.

Patient Engagement: 

• Uses various strategies, including phone calls, home visits, and community outreach, to engage patients and ensure continuous participation in their care.

Time Management & Organization: 

• Demonstrates strong organizational skills by managing patient caseloads, schedules, and documentation efficiently.

Technology Proficiency: 

• Skilled in using electronic health records (EMR) systems and other digital tools to document patient information and communicate within the team.

Motivational Interviewing & Patient-Centered Care: 

• Uses motivational interviewing techniques to build rapport and empower patients to take ownership of their health decisions.

Data Management: 

• Ensures accurate and timely documentation of patient data, ensuring continuity of care and compliance with organizational standards.

Outcome-Oriented Approach: 

• Focuses on achieving key health outcomes, such as improved care adherence, reduction in emergency room visits, and enhanced self-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. 

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 Nurse Care Manager is a field-based role responsible for care coordination of high-risk patients who require comprehensive care plans addressing chronic conditions. The Nurse Care Manager works with a multidisciplinary Care Team, collaborating to ensure optimal health outcomes for patients through personalized care plans, self-management, and disease prevention. This role focuses on chronic care management and care transitions, particularly for patients discharged from inpatient settings, and involves both in-person and telephonic outreach, medication reconciliation, and ensuring continuity of care across the healthcare ecosystem. The Nurse Care Manager acts as an advocate for patients and ensures the integration of services across providers, hospitals, and outpatient services.

Skills Required:

• Registered nursing license (unrestricted)
• Expertise in care management and coordination across healthcare providers
• Strong communication skills for patient and caregiver education
• Ability to conduct both in-home and telephonic assessments, care plans, and medication reconciliations
• Experience with EHR systems and real-time documentation
• Ability to work independently and manage multiple patient cases
• Critical thinking and decision-making skills in developing care plans
• Proficient in using digital tools for care coordination and communication
• A valid driver’s license and auto liability insurance
• Reliable transportation and the ability to travel within assigned territory or as needed
• Case management certification is a plus but not required

Key Behaviors:

Patient-Centered Care:

• Develops strong relationships with patients and caregivers, advocating for their needs and ensuring they understand and follow their care plans.

Collaboration:

• Works effectively with the multidisciplinary Care Team Pod to ensure seamless care across all providers and services.

Proactive Communication:

• Actively reaches out to patients and caregivers within 48 hours of discharge to ensure smooth transitions and minimize gaps in care.

Advocacy and Education:

• Provides clear, compassionate education to patients and families about treatment options and ensures patients are empowered to manage their health.

Care Coordination:

• Ensures that care is effectively coordinated across multiple providers, institutions, and services, particularly during transitions of care.

Time Management:

• Effectively manages patient caseloads, balancing multiple tasks while adhering to deadlines and care plans.

Problem Solving:

• Identifies potential gaps in care, resolves issues through collaboration with providers, and works to optimize patient outcomes.

Confidentiality:

• Maintains patient confidentiality and follows HIPAA regulations to ensure privacy in all interactions.

Cultural Competence:

• Demonstrates respect for diversity, ensuring culturally sensitive care that meets the needs of diverse patient populations.

Competencies:

Clinical Expertise:

• Strong knowledge of chronic disease management, care transitions, and evidence-based practices to develop and implement care plans.

Effective Communication:

• Skilled at delivering complex medical information clearly to patients, caregivers, and interdisciplinary teams.

Care Plan Development:

• Proficient in creating personalized care plans that address physical, behavioral, and social health needs.

Technology Proficiency:

• Ability to use electronic health records (EHR) and care management systems to document, track, and coordinate patient care.

Outcome-Oriented:

• Focused on achieving optimal clinical and financial outcomes for patients through effective care coordination and management.

Independent and Team-Oriented:

• Able to work independently in a remote environment while also collaborating effectively with a multidisciplinary team.

Critical Thinking:

• Uses clinical judgment to assess, analyze, and evaluate patient progress, adapting care plans as needed to achieve optimal results.

Multitasking and Prioritization:

• Manages multiple patient cases simultaneously while prioritizing tasks to meet deadlines and ensure comprehensive care.

Patient Engagement:

• Motivates patients to follow care plans and improve self-care skills through regular communication and support.

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.

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 Community Outreach Specialist (COS) plays a critical role in establishing Upward Health’s presence in the community and reaching potential patients. As the first point of contact for individuals seeking our services, the COS is responsible for educating patients about Upward Health’s offerings, engaging them in meaningful conversations, and facilitating their enrollment into our programs. The COS manages a personal caseload, primarily utilizing phone outreach, but also employing in-person visits and other community-based strategies as needed. This role is essential in ensuring that patients understand the full range of services available to them and helps them take the first steps toward improving their health. The COS reports to the Outreach Manager and works closely with other team members to ensure the overall success of patient outreach and engagement efforts.

Skills Required:

• Strong verbal communication and persuasive abilities
• Excellent interpersonal skills with the ability to build trust and rapport quickly
• Strong organizational and multitasking skills to manage a personal caseload efficiently
• Self-motivated with the ability to work independently and meet outreach goals
• Comfortable with fast-paced environments and adapting outreach methods to various situations
• Proficient in using computer systems for documentation, communication, and managing outreach activities
• Flexible and adaptable to a variety of outreach methods, including phone, in-person meetings, and mailings
• Fluent in English; Spanish proficiency is a plus

Key Behaviors:

Engagement: 

• Proactively builds relationships with potential patients, ensuring they feel informed and supported throughout their journey with Upward Health.

Resilience: 

• Demonstrates the ability to overcome objections and challenges, staying motivated to engage patients even in difficult situations.

Adaptability: 

• Flexibly adjusts outreach strategies based on the needs and preferences of patients, ensuring effective communication at all times.

Team Collaboration: 

• Works well within a team, sharing knowledge, providing support, and contributing to the collective goals of the outreach program.

Efficiency: 

• Effectively manages time to meet outreach goals, balancing a caseload and ensuring timely follow-ups with patients.

Compassion: 

• Approaches patient interactions with empathy, ensuring each patient feels heard and understood.

Cultural Competency: 

• Demonstrates respect for diverse backgrounds and works effectively with individuals from various cultural and socioeconomic backgrounds.

Competencies:

Communication: 

• Ability to clearly and persuasively communicate Upward Health’s services and benefits to potential patients, making complex information easy to understand.

Patient Engagement: 

• Skilled in enrolling patients into Upward Health’s programs and ensuring they have a smooth onboarding experience.

Customer-Centric: 

• Always focused on the needs of the patient, ensuring excellent service throughout the outreach process and helping patients access the right services.

Problem Solving: 

• Capable of addressing patient concerns or objections during outreach efforts, ensuring positive outcomes and maintaining trust.

Time Management: 

• Demonstrates excellent time management by balancing outreach activities, managing caseloads, and meeting set goals within a fast-paced environment.

Data Management: 

• Attention to detail when documenting patient information, ensuring accuracy and timely updates in the company’s systems.

Community Knowledge:

• Familiarity with local resources and the ability to connect patients to additional community-based services that may be beneficial to their care.

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.

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 Nurse Care Manager is a field-based role responsible for care coordination of high-risk patients who require comprehensive care plans addressing chronic conditions. The Nurse Care Manager works with a multidisciplinary Care Team, collaborating to ensure optimal health outcomes for patients through personalized care plans, self-management, and disease prevention. This role focuses on chronic care management and care transitions, particularly for patients discharged from inpatient settings, and involves both in-person and telephonic outreach, medication reconciliation, and ensuring continuity of care across the healthcare ecosystem. The Nurse Care Manager acts as an advocate for patients and ensures the integration of services across providers, hospitals, and outpatient services.

Skills Required:

• Registered nursing license (unrestricted)
• Expertise in care management and coordination across healthcare providers
• Strong communication skills for patient and caregiver education
• Ability to conduct both in-home and telephonic assessments, care plans, and medication reconciliations
• Experience with EHR systems and real-time documentation
• Ability to work independently and manage multiple patient cases
• Critical thinking and decision-making skills in developing care plans
• Proficient in using digital tools for care coordination and communication
• A valid driver’s license and auto liability insurance
• Reliable transportation and the ability to travel within assigned territory or as needed
• Case management certification is a plus but not required

Key Behaviors:

Patient-Centered Care:

• Develops strong relationships with patients and caregivers, advocating for their needs and ensuring they understand and follow their care plans.

Collaboration:

• Works effectively with the multidisciplinary Care Team Pod to ensure seamless care across all providers and services.

Proactive Communication:

• Actively reaches out to patients and caregivers within 48 hours of discharge to ensure smooth transitions and minimize gaps in care.

Advocacy and Education:

• Provides clear, compassionate education to patients and families about treatment options and ensures patients are empowered to manage their health.

Care Coordination:

• Ensures that care is effectively coordinated across multiple providers, institutions, and services, particularly during transitions of care.

Time Management:

• Effectively manages patient caseloads, balancing multiple tasks while adhering to deadlines and care plans.

Problem Solving:

• Identifies potential gaps in care, resolves issues through collaboration with providers, and works to optimize patient outcomes.

Confidentiality:

• Maintains patient confidentiality and follows HIPAA regulations to ensure privacy in all interactions.

Cultural Competence:

• Demonstrates respect for diversity, ensuring culturally sensitive care that meets the needs of diverse patient populations.

Competencies:

Clinical Expertise:

• Strong knowledge of chronic disease management, care transitions, and evidence-based practices to develop and implement care plans.

Effective Communication:

• Skilled at delivering complex medical information clearly to patients, caregivers, and interdisciplinary teams.

Care Plan Development:

• Proficient in creating personalized care plans that address physical, behavioral, and social health needs.

Technology Proficiency:

• Ability to use electronic health records (EHR) and care management systems to document, track, and coordinate patient care.

Outcome-Oriented:

• Focused on achieving optimal clinical and financial outcomes for patients through effective care coordination and management.

Independent and Team-Oriented:

• Able to work independently in a remote environment while also collaborating effectively with a multidisciplinary team.

Critical Thinking:

• Uses clinical judgment to assess, analyze, and evaluate patient progress, adapting care plans as needed to achieve optimal results.

Multitasking and Prioritization:

• Manages multiple patient cases simultaneously while prioritizing tasks to meet deadlines and ensure comprehensive care.

Patient Engagement:

• Motivates patients to follow care plans and improve self-care skills through regular communication and support.

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.

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 is a key member of the team responsible for delivering chronic care management to high-complexity patients. The Care Specialist primarily works in patients' homes and communities (90% of the time) and engages in virtual care (10% of the time). This role involves direct outreach to patients, guiding them through the enrollment process, facilitating virtual appointments with providers, and ensuring that patients adhere to care plans. By building relationships, coordinating care, and providing education, the Care Specialist plays a critical role in promoting health, preventing unnecessary hospitalizations, and improving patient outcomes.

Skills Required:

• Minimum of 2 years of relevant work experience (e.g., Community Health Worker, Peer Support Specialist, Medical Assistant, etc.).
• High school diploma or GED required.
• A valid driver’s license, auto liability insurance, and reliable transportation to travel within the assigned territory.
• Experience in chronic care management or working with chronically ill/elderly patients.
• Technologically proficient with basic computer skills (typing, using EMR systems).
• Experience with motivational interviewing, trauma-informed care, and care coordination.
• Strong interpersonal communication skills with the ability to engage patients and team members effectively.
• Ability to prioritize tasks, manage schedules, and work independently in an unstructured environment.
• Multi-lingual skills are a plus but not required.
• Prior home care experience is beneficial.

Key Behaviors:

Adaptability & Resilience: 

• Ability to thrive in unstructured environments and pivot as needed to meet patient needs. Demonstrates perseverance in challenging situations.

Self-Starter & Motivation: 

• Proactively takes initiative in managing patient care and outreach. Willingness to learn and adapt to new processes and systems.

Empathy & Compassion: 

• Ability to work with individuals from diverse backgrounds and understand their complex needs. Skilled in building rapport through motivational interviewing and other patient-centered communication techniques.

Accountability & Integrity: 

• Demonstrates personal responsibility and takes ownership of tasks, ensuring accuracy and timeliness in all activities.

Cultural Competence: 

• Awareness of community dynamics and diversity, ensuring culturally sensitive and inclusive care.

Team Collaboration: 

• Works collaboratively with interdisciplinary teams to meet patient and organizational goals.

Problem-Solving & Critical Thinking: 

• Strong critical thinking skills to assess patient needs, analyze data, and develop appropriate care strategies.

Communication Skills: 

• Excellent verbal and written communication, capable of explaining complex medical information to patients in a clear and supportive manner.

Competencies:

Care Coordination: 

• Ability to engage patients in a comprehensive care plan, facilitating communication between patients, providers, and family members to ensure timely, effective care.

Health Education: 

• Effectively educates patients about their medical conditions, care plans, and available resources, ensuring that patients can make informed decisions.

Patient Engagement: 

• Uses various strategies, including phone calls, home visits, and community outreach, to engage patients and ensure continuous participation in their care.

Time Management & Organization: 

• Demonstrates strong organizational skills by managing patient caseloads, schedules, and documentation efficiently.

Technology Proficiency: 

• Skilled in using electronic health records (EMR) systems and other digital tools to document patient information and communicate within the team.

Motivational Interviewing & Patient-Centered Care: 

• Uses motivational interviewing techniques to build rapport and empower patients to take ownership of their health decisions.

Data Management: 

• Ensures accurate and timely documentation of patient data, ensuring continuity of care and compliance with organizational standards.

Outcome-Oriented Approach: 

• Focuses on achieving key health outcomes, such as improved care adherence, reduction in emergency room visits, and enhanced self-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. 

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 Community Outreach Specialist (COS) plays a critical role in establishing Upward Health’s presence in the community and reaching potential patients. As the first point of contact for individuals seeking our services, the COS is responsible for educating patients about Upward Health’s offerings, engaging them in meaningful conversations, and facilitating their enrollment into our programs. The COS manages a personal caseload, primarily utilizing phone outreach, but also employing in-person visits and other community-based strategies as needed. This role is essential in ensuring that patients understand the full range of services available to them and helps them take the first steps toward improving their health. The COS reports to the Outreach Manager and works closely with other team members to ensure the overall success of patient outreach and engagement efforts.

Skills Required:

• Strong verbal communication and persuasive abilities
• Excellent interpersonal skills with the ability to build trust and rapport quickly
• Strong organizational and multitasking skills to manage a personal caseload efficiently
• Self-motivated with the ability to work independently and meet outreach goals
• Comfortable with fast-paced environments and adapting outreach methods to various situations
• Proficient in using computer systems for documentation, communication, and managing outreach activities
• Flexible and adaptable to a variety of outreach methods, including phone, in-person meetings, and mailings
• Fluent in English; Spanish proficiency is a plus

Key Behaviors:

Engagement: 

• Proactively builds relationships with potential patients, ensuring they feel informed and supported throughout their journey with Upward Health.

Resilience: 

• Demonstrates the ability to overcome objections and challenges, staying motivated to engage patients even in difficult situations.

Adaptability: 

• Flexibly adjusts outreach strategies based on the needs and preferences of patients, ensuring effective communication at all times.

Team Collaboration: 

• Works well within a team, sharing knowledge, providing support, and contributing to the collective goals of the outreach program.

Efficiency: 

• Effectively manages time to meet outreach goals, balancing a caseload and ensuring timely follow-ups with patients.

Compassion: 

• Approaches patient interactions with empathy, ensuring each patient feels heard and understood.

Cultural Competency: 

• Demonstrates respect for diverse backgrounds and works effectively with individuals from various cultural and socioeconomic backgrounds.

Competencies:

Communication: 

• Ability to clearly and persuasively communicate Upward Health’s services and benefits to potential patients, making complex information easy to understand.

Patient Engagement: 

• Skilled in enrolling patients into Upward Health’s programs and ensuring they have a smooth onboarding experience.

Customer-Centric: 

• Always focused on the needs of the patient, ensuring excellent service throughout the outreach process and helping patients access the right services.

Problem Solving: 

• Capable of addressing patient concerns or objections during outreach efforts, ensuring positive outcomes and maintaining trust.

Time Management: 

• Demonstrates excellent time management by balancing outreach activities, managing caseloads, and meeting set goals within a fast-paced environment.

Data Management: 

• Attention to detail when documenting patient information, ensuring accuracy and timely updates in the company’s systems.

Community Knowledge:

• Familiarity with local resources and the ability to connect patients to additional community-based services that may be beneficial to their care.

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.

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 is a key member of the team responsible for delivering chronic care management to high-complexity patients. The Care Specialist primarily works in patients' homes and communities (90% of the time) and engages in virtual care (10% of the time). This role involves direct outreach to patients, guiding them through the enrollment process, facilitating virtual appointments with providers, and ensuring that patients adhere to care plans. By building relationships, coordinating care, and providing education, the Care Specialist plays a critical role in promoting health, preventing unnecessary hospitalizations, and improving patient outcomes.

Skills Required:

• Minimum of 2 years of relevant work experience (e.g., Community Health Worker, Peer Support Specialist, Medical Assistant, etc.).
• High school diploma or GED required.
• A valid driver’s license, auto liability insurance, and reliable transportation to travel within the assigned territory.
• Experience in chronic care management or working with chronically ill/elderly patients.
• Technologically proficient with basic computer skills (typing, using EMR systems).
• Experience with motivational interviewing, trauma-informed care, and care coordination.
• Strong interpersonal communication skills with the ability to engage patients and team members effectively.
• Ability to prioritize tasks, manage schedules, and work independently in an unstructured environment.
• Multi-lingual skills are a plus but not required.
• Prior home care experience is beneficial.

Key Behaviors:

Adaptability & Resilience: 

• Ability to thrive in unstructured environments and pivot as needed to meet patient needs. Demonstrates perseverance in challenging situations.

Self-Starter & Motivation: 

• Proactively takes initiative in managing patient care and outreach. Willingness to learn and adapt to new processes and systems.

Empathy & Compassion: 

• Ability to work with individuals from diverse backgrounds and understand their complex needs. Skilled in building rapport through motivational interviewing and other patient-centered communication techniques.

Accountability & Integrity: 

• Demonstrates personal responsibility and takes ownership of tasks, ensuring accuracy and timeliness in all activities.

Cultural Competence: 

• Awareness of community dynamics and diversity, ensuring culturally sensitive and inclusive care.

Team Collaboration: 

• Works collaboratively with interdisciplinary teams to meet patient and organizational goals.

Problem-Solving & Critical Thinking: 

• Strong critical thinking skills to assess patient needs, analyze data, and develop appropriate care strategies.

Communication Skills: 

• Excellent verbal and written communication, capable of explaining complex medical information to patients in a clear and supportive manner.

Competencies:

Care Coordination: 

• Ability to engage patients in a comprehensive care plan, facilitating communication between patients, providers, and family members to ensure timely, effective care.

Health Education: 

• Effectively educates patients about their medical conditions, care plans, and available resources, ensuring that patients can make informed decisions.

Patient Engagement: 

• Uses various strategies, including phone calls, home visits, and community outreach, to engage patients and ensure continuous participation in their care.

Time Management & Organization: 

• Demonstrates strong organizational skills by managing patient caseloads, schedules, and documentation efficiently.

Technology Proficiency: 

• Skilled in using electronic health records (EMR) systems and other digital tools to document patient information and communicate within the team.

Motivational Interviewing & Patient-Centered Care: 

• Uses motivational interviewing techniques to build rapport and empower patients to take ownership of their health decisions.

Data Management: 

• Ensures accurate and timely documentation of patient data, ensuring continuity of care and compliance with organizational standards.

Outcome-Oriented Approach: 

• Focuses on achieving key health outcomes, such as improved care adherence, reduction in emergency room visits, and enhanced self-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. 

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 is a key member of the team responsible for delivering chronic care management to high-complexity patients. The Care Specialist primarily works in patients' homes and communities (90% of the time) and engages in virtual care (10% of the time). This role involves direct outreach to patients, guiding them through the enrollment process, facilitating virtual appointments with providers, and ensuring that patients adhere to care plans. By building relationships, coordinating care, and providing education, the Care Specialist plays a critical role in promoting health, preventing unnecessary hospitalizations, and improving patient outcomes.

Skills Required:

• Minimum of 2 years of relevant work experience (e.g., Community Health Worker, Peer Support Specialist, Medical Assistant, etc.).
• High school diploma or GED required.
• A valid driver’s license, auto liability insurance, and reliable transportation to travel within the assigned territory.
• Experience in chronic care management or working with chronically ill/elderly patients.
• Technologically proficient with basic computer skills (typing, using EMR systems).
• Experience with motivational interviewing, trauma-informed care, and care coordination.
• Strong interpersonal communication skills with the ability to engage patients and team members effectively.
• Ability to prioritize tasks, manage schedules, and work independently in an unstructured environment.
• Multi-lingual skills are a plus but not required.
• Prior home care experience is beneficial.

Key Behaviors:

Adaptability & Resilience: 

• Ability to thrive in unstructured environments and pivot as needed to meet patient needs. Demonstrates perseverance in challenging situations.

Self-Starter & Motivation: 

• Proactively takes initiative in managing patient care and outreach. Willingness to learn and adapt to new processes and systems.

Empathy & Compassion: 

• Ability to work with individuals from diverse backgrounds and understand their complex needs. Skilled in building rapport through motivational interviewing and other patient-centered communication techniques.

Accountability & Integrity: 

• Demonstrates personal responsibility and takes ownership of tasks, ensuring accuracy and timeliness in all activities.

Cultural Competence: 

• Awareness of community dynamics and diversity, ensuring culturally sensitive and inclusive care.

Team Collaboration: 

• Works collaboratively with interdisciplinary teams to meet patient and organizational goals.

Problem-Solving & Critical Thinking: 

• Strong critical thinking skills to assess patient needs, analyze data, and develop appropriate care strategies.

Communication Skills: 

• Excellent verbal and written communication, capable of explaining complex medical information to patients in a clear and supportive manner.

Competencies:

Care Coordination: 

• Ability to engage patients in a comprehensive care plan, facilitating communication between patients, providers, and family members to ensure timely, effective care.

Health Education: 

• Effectively educates patients about their medical conditions, care plans, and available resources, ensuring that patients can make informed decisions.

Patient Engagement: 

• Uses various strategies, including phone calls, home visits, and community outreach, to engage patients and ensure continuous participation in their care.

Time Management & Organization: 

• Demonstrates strong organizational skills by managing patient caseloads, schedules, and documentation efficiently.

Technology Proficiency: 

• Skilled in using electronic health records (EMR) systems and other digital tools to document patient information and communicate within the team.

Motivational Interviewing & Patient-Centered Care: 

• Uses motivational interviewing techniques to build rapport and empower patients to take ownership of their health decisions.

Data Management: 

• Ensures accurate and timely documentation of patient data, ensuring continuity of care and compliance with organizational standards.

Outcome-Oriented Approach: 

• Focuses on achieving key health outcomes, such as improved care adherence, reduction in emergency room visits, and enhanced self-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. 

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 Community Outreach Specialist (COS) plays a critical role in establishing Upward Health’s presence in the community and reaching potential patients. As the first point of contact for individuals seeking our services, the COS is responsible for educating patients about Upward Health’s offerings, engaging them in meaningful conversations, and facilitating their enrollment into our programs. The COS manages a personal caseload, primarily utilizing phone outreach, but also employing in-person visits and other community-based strategies as needed. This role is essential in ensuring that patients understand the full range of services available to them and helps them take the first steps toward improving their health. The COS reports to the Outreach Manager and works closely with other team members to ensure the overall success of patient outreach and engagement efforts.

Skills Required:

• Strong verbal communication and persuasive abilities
• Excellent interpersonal skills with the ability to build trust and rapport quickly
• Strong organizational and multitasking skills to manage a personal caseload efficiently
• Self-motivated with the ability to work independently and meet outreach goals
• Comfortable with fast-paced environments and adapting outreach methods to various situations
• Proficient in using computer systems for documentation, communication, and managing outreach activities
• Flexible and adaptable to a variety of outreach methods, including phone, in-person meetings, and mailings
• Fluent in English; Spanish proficiency is a plus

Key Behaviors:

Engagement: 

• Proactively builds relationships with potential patients, ensuring they feel informed and supported throughout their journey with Upward Health.

Resilience: 

• Demonstrates the ability to overcome objections and challenges, staying motivated to engage patients even in difficult situations.

Adaptability: 

• Flexibly adjusts outreach strategies based on the needs and preferences of patients, ensuring effective communication at all times.

Team Collaboration: 

• Works well within a team, sharing knowledge, providing support, and contributing to the collective goals of the outreach program.

Efficiency: 

• Effectively manages time to meet outreach goals, balancing a caseload and ensuring timely follow-ups with patients.

Compassion: 

• Approaches patient interactions with empathy, ensuring each patient feels heard and understood.

Cultural Competency: 

• Demonstrates respect for diverse backgrounds and works effectively with individuals from various cultural and socioeconomic backgrounds.

Competencies:

Communication: 

• Ability to clearly and persuasively communicate Upward Health’s services and benefits to potential patients, making complex information easy to understand.

Patient Engagement: 

• Skilled in enrolling patients into Upward Health’s programs and ensuring they have a smooth onboarding experience.

Customer-Centric: 

• Always focused on the needs of the patient, ensuring excellent service throughout the outreach process and helping patients access the right services.

Problem Solving: 

• Capable of addressing patient concerns or objections during outreach efforts, ensuring positive outcomes and maintaining trust.

Time Management: 

• Demonstrates excellent time management by balancing outreach activities, managing caseloads, and meeting set goals within a fast-paced environment.

Data Management: 

• Attention to detail when documenting patient information, ensuring accuracy and timely updates in the company’s systems.

Community Knowledge:

• Familiarity with local resources and the ability to connect patients to additional community-based services that may be beneficial to their care.

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.

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.
• At least 2 years of Pediatric experience involving Community Referrals, Care Coordination, Navigation of Healthcare Providers and Services, or Management of Healthcare Support Resources.
• 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.

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 is a key member of the team responsible for delivering chronic care management to high-complexity patients. The Care Specialist primarily works in patients' homes and communities (90% of the time) and engages in virtual care (10% of the time). This role involves direct outreach to patients, guiding them through the enrollment process, facilitating virtual appointments with providers, and ensuring that patients adhere to care plans. By building relationships, coordinating care, and providing education, the Care Specialist plays a critical role in promoting health, preventing unnecessary hospitalizations, and improving patient outcomes.

Skills Required:

• Minimum of 2 years of relevant work experience (e.g., Community Health Worker, Peer Support Specialist, Medical Assistant, etc.).
• High school diploma or GED required.
• A valid driver’s license, auto liability insurance, and reliable transportation to travel within the assigned territory.
• Experience in chronic care management or working with chronically ill/elderly patients.
• Technologically proficient with basic computer skills (typing, using EMR systems).
• Experience with motivational interviewing, trauma-informed care, and care coordination.
• Strong interpersonal communication skills with the ability to engage patients and team members effectively.
• Ability to prioritize tasks, manage schedules, and work independently in an unstructured environment.
• Multi-lingual skills are a plus but not required.
• Prior home care experience is beneficial.

Key Behaviors:

Adaptability & Resilience: 

• Ability to thrive in unstructured environments and pivot as needed to meet patient needs. Demonstrates perseverance in challenging situations.

Self-Starter & Motivation: 

• Proactively takes initiative in managing patient care and outreach. Willingness to learn and adapt to new processes and systems.

Empathy & Compassion: 

• Ability to work with individuals from diverse backgrounds and understand their complex needs. Skilled in building rapport through motivational interviewing and other patient-centered communication techniques.

Accountability & Integrity: 

• Demonstrates personal responsibility and takes ownership of tasks, ensuring accuracy and timeliness in all activities.

Cultural Competence: 

• Awareness of community dynamics and diversity, ensuring culturally sensitive and inclusive care.

Team Collaboration: 

• Works collaboratively with interdisciplinary teams to meet patient and organizational goals.

Problem-Solving & Critical Thinking: 

• Strong critical thinking skills to assess patient needs, analyze data, and develop appropriate care strategies.

Communication Skills: 

• Excellent verbal and written communication, capable of explaining complex medical information to patients in a clear and supportive manner.

Competencies:

Care Coordination: 

• Ability to engage patients in a comprehensive care plan, facilitating communication between patients, providers, and family members to ensure timely, effective care.

Health Education: 

• Effectively educates patients about their medical conditions, care plans, and available resources, ensuring that patients can make informed decisions.

Patient Engagement: 

• Uses various strategies, including phone calls, home visits, and community outreach, to engage patients and ensure continuous participation in their care.

Time Management & Organization: 

• Demonstrates strong organizational skills by managing patient caseloads, schedules, and documentation efficiently.

Technology Proficiency: 

• Skilled in using electronic health records (EMR) systems and other digital tools to document patient information and communicate within the team.

Motivational Interviewing & Patient-Centered Care: 

• Uses motivational interviewing techniques to build rapport and empower patients to take ownership of their health decisions.

Data Management: 

• Ensures accurate and timely documentation of patient data, ensuring continuity of care and compliance with organizational standards.

Outcome-Oriented Approach: 

• Focuses on achieving key health outcomes, such as improved care adherence, reduction in emergency room visits, and enhanced self-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. 

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 is a key member of the team responsible for delivering chronic care management to high-complexity patients. The Care Specialist primarily works in patients' homes and communities (90% of the time) and engages in virtual care (10% of the time). This role involves direct outreach to patients, guiding them through the enrollment process, facilitating virtual appointments with providers, and ensuring that patients adhere to care plans. By building relationships, coordinating care, and providing education, the Care Specialist plays a critical role in promoting health, preventing unnecessary hospitalizations, and improving patient outcomes.

Skills Required:

• Minimum of 2 years of relevant work experience (e.g., Community Health Worker, Peer Support Specialist, Medical Assistant, etc.).
• High school diploma or GED required.
• A valid driver’s license, auto liability insurance, and reliable transportation to travel within the assigned territory.
• Experience in chronic care management or working with chronically ill/elderly patients.
• Technologically proficient with basic computer skills (typing, using EMR systems).
• Experience with motivational interviewing, trauma-informed care, and care coordination.
• Strong interpersonal communication skills with the ability to engage patients and team members effectively.
• Ability to prioritize tasks, manage schedules, and work independently in an unstructured environment.
• Multi-lingual skills are a plus but not required.
• Prior home care experience is beneficial.

Key Behaviors:

Adaptability & Resilience: 

• Ability to thrive in unstructured environments and pivot as needed to meet patient needs. Demonstrates perseverance in challenging situations.

Self-Starter & Motivation: 

• Proactively takes initiative in managing patient care and outreach. Willingness to learn and adapt to new processes and systems.

Empathy & Compassion: 

• Ability to work with individuals from diverse backgrounds and understand their complex needs. Skilled in building rapport through motivational interviewing and other patient-centered communication techniques.

Accountability & Integrity: 

• Demonstrates personal responsibility and takes ownership of tasks, ensuring accuracy and timeliness in all activities.

Cultural Competence: 

• Awareness of community dynamics and diversity, ensuring culturally sensitive and inclusive care.

Team Collaboration: 

• Works collaboratively with interdisciplinary teams to meet patient and organizational goals.

Problem-Solving & Critical Thinking: 

• Strong critical thinking skills to assess patient needs, analyze data, and develop appropriate care strategies.

Communication Skills: 

• Excellent verbal and written communication, capable of explaining complex medical information to patients in a clear and supportive manner.

Competencies:

Care Coordination: 

• Ability to engage patients in a comprehensive care plan, facilitating communication between patients, providers, and family members to ensure timely, effective care.

Health Education: 

• Effectively educates patients about their medical conditions, care plans, and available resources, ensuring that patients can make informed decisions.

Patient Engagement: 

• Uses various strategies, including phone calls, home visits, and community outreach, to engage patients and ensure continuous participation in their care.

Time Management & Organization: 

• Demonstrates strong organizational skills by managing patient caseloads, schedules, and documentation efficiently.

Technology Proficiency: 

• Skilled in using electronic health records (EMR) systems and other digital tools to document patient information and communicate within the team.

Motivational Interviewing & Patient-Centered Care: 

• Uses motivational interviewing techniques to build rapport and empower patients to take ownership of their health decisions.

Data Management: 

• Ensures accurate and timely documentation of patient data, ensuring continuity of care and compliance with organizational standards.

Outcome-Oriented Approach: 

• Focuses on achieving key health outcomes, such as improved care adherence, reduction in emergency room visits, and enhanced self-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. 

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 is a key member of the team responsible for delivering chronic care management to high-complexity patients. The Care Specialist primarily works in patients' homes and communities (90% of the time) and engages in virtual care (10% of the time). This role involves direct outreach to patients, guiding them through the enrollment process, facilitating virtual appointments with providers, and ensuring that patients adhere to care plans. By building relationships, coordinating care, and providing education, the Care Specialist plays a critical role in promoting health, preventing unnecessary hospitalizations, and improving patient outcomes.

Skills Required:

• Minimum of 2 years of relevant work experience (e.g., Community Health Worker, Peer Support Specialist, Medical Assistant, etc.).
• High school diploma or GED required.
• A valid driver’s license, auto liability insurance, and reliable transportation to travel within the assigned territory.
• Experience in chronic care management or working with chronically ill/elderly patients.
• Technologically proficient with basic computer skills (typing, using EMR systems).
• Experience with motivational interviewing, trauma-informed care, and care coordination.
• Strong interpersonal communication skills with the ability to engage patients and team members effectively.
• Ability to prioritize tasks, manage schedules, and work independently in an unstructured environment.
• Multi-lingual skills are a plus but not required.
• Prior home care experience is beneficial.

Key Behaviors:

Adaptability & Resilience: 

• Ability to thrive in unstructured environments and pivot as needed to meet patient needs. Demonstrates perseverance in challenging situations.

Self-Starter & Motivation: 

• Proactively takes initiative in managing patient care and outreach. Willingness to learn and adapt to new processes and systems.

Empathy & Compassion: 

• Ability to work with individuals from diverse backgrounds and understand their complex needs. Skilled in building rapport through motivational interviewing and other patient-centered communication techniques.

Accountability & Integrity: 

• Demonstrates personal responsibility and takes ownership of tasks, ensuring accuracy and timeliness in all activities.

Cultural Competence: 

• Awareness of community dynamics and diversity, ensuring culturally sensitive and inclusive care.

Team Collaboration: 

• Works collaboratively with interdisciplinary teams to meet patient and organizational goals.

Problem-Solving & Critical Thinking: 

• Strong critical thinking skills to assess patient needs, analyze data, and develop appropriate care strategies.

Communication Skills: 

• Excellent verbal and written communication, capable of explaining complex medical information to patients in a clear and supportive manner.

Competencies:

Care Coordination: 

• Ability to engage patients in a comprehensive care plan, facilitating communication between patients, providers, and family members to ensure timely, effective care.

Health Education: 

• Effectively educates patients about their medical conditions, care plans, and available resources, ensuring that patients can make informed decisions.

Patient Engagement: 

• Uses various strategies, including phone calls, home visits, and community outreach, to engage patients and ensure continuous participation in their care.

Time Management & Organization: 

• Demonstrates strong organizational skills by managing patient caseloads, schedules, and documentation efficiently.

Technology Proficiency: 

• Skilled in using electronic health records (EMR) systems and other digital tools to document patient information and communicate within the team.

Motivational Interviewing & Patient-Centered Care: 

• Uses motivational interviewing techniques to build rapport and empower patients to take ownership of their health decisions.

Data Management: 

• Ensures accurate and timely documentation of patient data, ensuring continuity of care and compliance with organizational standards.

Outcome-Oriented Approach: 

• Focuses on achieving key health outcomes, such as improved care adherence, reduction in emergency room visits, and enhanced self-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. 

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 Transitions of Care Nurse (RN) is a field-based role focused on patients experiencing an admission, discharge, or transfer (ADT) event. This nurse responds to real-time ADT alerts, engages patients during hospitalization, and coordinates seamless transitions across care settings. The role ensures safe discharges, prevents avoidable readmissions, and supports patients through the critical first 90-day post-discharge.

Key Responsibilities

• Respond to ADT alerts in real time and deploy to the hospital at admission to enroll patients into Upward Health services.
• Collaborate with hospital staff, providers, and discharge planners to create safe transition plans.
• Conduct a home visit within 2 business days of discharge to reconcile medications, confirm follow-up appointments, and assess home safety.
• Address post-discharge needs, including arranging home health, physical therapy, or durable medical equipment.
• Provide care management for up to 90 days post-discharge, with a focus on preventing readmissions and supporting patient goals.
• Educate patients and caregivers on care plans, treatment adherence, and community resources.
• Document all encounters in the EHR in real time and communicate care updates to the multidisciplinary team.

Skills Required:

• Registered nursing license (unrestricted)
• Experience in hospital-based care coordination, case management, or transitions of care.
• Strong clinical assessment and critical thinking skills.
• Ability to perform in-home visits and collaborate across hospital and community settings.
• Excellent communication and patient education skills.
• Proficiency with electronic health records and digital care coordination tools.
• Reliable transportation, valid driver’s license, and auto insurance.
• Case management certification is a plus but not required

Competencies:

Clinical Expertise: 

• Strong knowledge of chronic disease management, care transitions, and evidence-based practices to develop and implement care plans.

Effective Communication: 

• Skilled at delivering complex medical information clearly to patients, caregivers, and interdisciplinary teams.

Care Plan Development: 

• Proficient in creating personalized care plans that address physical, behavioral, and social health needs.

Technology Proficiency: 

• Ability to use electronic health records (EHR) and care management systems to document, track, and coordinate patient care.

Outcome-Oriented: 

• Focused on achieving optimal clinical and financial outcomes for patients through effective care coordination and management.

Independent and Team-Oriented: 

• Able to work independently in a remote environment while also collaborating effectively with a multidisciplinary team.

Critical Thinking: 

• Uses clinical judgment to assess, analyze, and evaluate patient progress, adapting care plans as needed to achieve optimal results.

Multitasking and Prioritization: 

• Manages multiple patient cases simultaneously while prioritizing tasks to meet deadlines and ensure comprehensive care.

Patient Engagement: 

• Motivates patients to follow care plans and improve self-care skills through regular communication and support.

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.

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 Transitions of Care Nurse (RN) is a field-based role focused on patients experiencing an admission, discharge, or transfer (ADT) event. This nurse responds to real-time ADT alerts, engages patients during hospitalization, and coordinates seamless transitions across care settings. The role ensures safe discharges, prevents avoidable readmissions, and supports patients through the critical first 90-day post-discharge.

Key Responsibilities

• Respond to ADT alerts in real time and deploy to the hospital at admission to enroll patients into Upward Health services.
• Collaborate with hospital staff, providers, and discharge planners to create safe transition plans.
• Conduct a home visit within 2 business days of discharge to reconcile medications, confirm follow-up appointments, and assess home safety.
• Address post-discharge needs, including arranging home health, physical therapy, or durable medical equipment.
• Provide care management for up to 90 days post-discharge, with a focus on preventing readmissions and supporting patient goals.
• Educate patients and caregivers on care plans, treatment adherence, and community resources.
• Document all encounters in the EHR in real time and communicate care updates to the multidisciplinary team.

Skills Required:

• Registered nursing license (unrestricted)
• Experience in hospital-based care coordination, case management, or transitions of care.
• Strong clinical assessment and critical thinking skills.
• Ability to perform in-home visits and collaborate across hospital and community settings.
• Excellent communication and patient education skills.
• Proficiency with electronic health records and digital care coordination tools.
• Reliable transportation, valid driver’s license, and auto insurance.
• Case management certification is a plus but not required

Competencies:

Clinical Expertise: 

• Strong knowledge of chronic disease management, care transitions, and evidence-based practices to develop and implement care plans.

Effective Communication: 

• Skilled at delivering complex medical information clearly to patients, caregivers, and interdisciplinary teams.

Care Plan Development: 

• Proficient in creating personalized care plans that address physical, behavioral, and social health needs.

Technology Proficiency: 

• Ability to use electronic health records (EHR) and care management systems to document, track, and coordinate patient care.

Outcome-Oriented: 

• Focused on achieving optimal clinical and financial outcomes for patients through effective care coordination and management.

Independent and Team-Oriented: 

• Able to work independently in a remote environment while also collaborating effectively with a multidisciplinary team.

Critical Thinking: 

• Uses clinical judgment to assess, analyze, and evaluate patient progress, adapting care plans as needed to achieve optimal results.

Multitasking and Prioritization: 

• Manages multiple patient cases simultaneously while prioritizing tasks to meet deadlines and ensure comprehensive care.

Patient Engagement: 

• Motivates patients to follow care plans and improve self-care skills through regular communication and support.

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.

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 is a key member of the team responsible for delivering chronic care management to high-complexity patients. The Care Specialist primarily works in patients' homes and communities (90% of the time) and engages in virtual care (10% of the time). This role involves direct outreach to patients, guiding them through the enrollment process, facilitating virtual appointments with providers, and ensuring that patients adhere to care plans. By building relationships, coordinating care, and providing education, the Care Specialist plays a critical role in promoting health, preventing unnecessary hospitalizations, and improving patient outcomes.

Skills Required:

• Minimum of 2 years of relevant work experience (e.g., Community Health Worker, Peer Support Specialist, Medical Assistant, etc.).
• High school diploma or GED required.
• A valid driver’s license, auto liability insurance, and reliable transportation to travel within the assigned territory.
• Experience in chronic care management or working with chronically ill/elderly patients.
• Technologically proficient with basic computer skills (typing, using EMR systems).
• Experience with motivational interviewing, trauma-informed care, and care coordination.
• Strong interpersonal communication skills with the ability to engage patients and team members effectively.
• Ability to prioritize tasks, manage schedules, and work independently in an unstructured environment.
• Multi-lingual skills are a plus but not required.
• Prior home care experience is beneficial.

Key Behaviors:

Adaptability & Resilience: 

• Ability to thrive in unstructured environments and pivot as needed to meet patient needs. Demonstrates perseverance in challenging situations.

Self-Starter & Motivation: 

• Proactively takes initiative in managing patient care and outreach. Willingness to learn and adapt to new processes and systems.

Empathy & Compassion: 

• Ability to work with individuals from diverse backgrounds and understand their complex needs. Skilled in building rapport through motivational interviewing and other patient-centered communication techniques.

Accountability & Integrity: 

• Demonstrates personal responsibility and takes ownership of tasks, ensuring accuracy and timeliness in all activities.

Cultural Competence: 

• Awareness of community dynamics and diversity, ensuring culturally sensitive and inclusive care.

Team Collaboration: 

• Works collaboratively with interdisciplinary teams to meet patient and organizational goals.

Problem-Solving & Critical Thinking: 

• Strong critical thinking skills to assess patient needs, analyze data, and develop appropriate care strategies.

Communication Skills: 

• Excellent verbal and written communication, capable of explaining complex medical information to patients in a clear and supportive manner.

Competencies:

Care Coordination: 

• Ability to engage patients in a comprehensive care plan, facilitating communication between patients, providers, and family members to ensure timely, effective care.

Health Education: 

• Effectively educates patients about their medical conditions, care plans, and available resources, ensuring that patients can make informed decisions.

Patient Engagement: 

• Uses various strategies, including phone calls, home visits, and community outreach, to engage patients and ensure continuous participation in their care.

Time Management & Organization: 

• Demonstrates strong organizational skills by managing patient caseloads, schedules, and documentation efficiently.

Technology Proficiency: 

• Skilled in using electronic health records (EMR) systems and other digital tools to document patient information and communicate within the team.

Motivational Interviewing & Patient-Centered Care: 

• Uses motivational interviewing techniques to build rapport and empower patients to take ownership of their health decisions.

Data Management: 

• Ensures accurate and timely documentation of patient data, ensuring continuity of care and compliance with organizational standards.

Outcome-Oriented Approach: 

• Focuses on achieving key health outcomes, such as improved care adherence, reduction in emergency room visits, and enhanced self-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. 

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 is a key member of the team responsible for delivering chronic care management to high-complexity patients. The Care Specialist primarily works in patients' homes and communities (90% of the time) and engages in virtual care (10% of the time). This role involves direct outreach to patients, guiding them through the enrollment process, facilitating virtual appointments with providers, and ensuring that patients adhere to care plans. By building relationships, coordinating care, and providing education, the Care Specialist plays a critical role in promoting health, preventing unnecessary hospitalizations, and improving patient outcomes.

Skills Required:

• Minimum of 2 years of relevant work experience (e.g., Community Health Worker, Peer Support Specialist, Medical Assistant, etc.).
• High school diploma or GED required.
• A valid driver’s license, auto liability insurance, and reliable transportation to travel within the assigned territory.
• Experience in chronic care management or working with chronically ill/elderly patients.
• Technologically proficient with basic computer skills (typing, using EMR systems).
• Experience with motivational interviewing, trauma-informed care, and care coordination.
• Strong interpersonal communication skills with the ability to engage patients and team members effectively.
• Ability to prioritize tasks, manage schedules, and work independently in an unstructured environment.
• Multi-lingual skills are a plus but not required.
• Prior home care experience is beneficial.

Key Behaviors:

Adaptability & Resilience: 

• Ability to thrive in unstructured environments and pivot as needed to meet patient needs. Demonstrates perseverance in challenging situations.

Self-Starter & Motivation: 

• Proactively takes initiative in managing patient care and outreach. Willingness to learn and adapt to new processes and systems.

Empathy & Compassion: 

• Ability to work with individuals from diverse backgrounds and understand their complex needs. Skilled in building rapport through motivational interviewing and other patient-centered communication techniques.

Accountability & Integrity: 

• Demonstrates personal responsibility and takes ownership of tasks, ensuring accuracy and timeliness in all activities.

Cultural Competence: 

• Awareness of community dynamics and diversity, ensuring culturally sensitive and inclusive care.

Team Collaboration: 

• Works collaboratively with interdisciplinary teams to meet patient and organizational goals.

Problem-Solving & Critical Thinking: 

• Strong critical thinking skills to assess patient needs, analyze data, and develop appropriate care strategies.

Communication Skills: 

• Excellent verbal and written communication, capable of explaining complex medical information to patients in a clear and supportive manner.

Competencies:

Care Coordination: 

• Ability to engage patients in a comprehensive care plan, facilitating communication between patients, providers, and family members to ensure timely, effective care.

Health Education: 

• Effectively educates patients about their medical conditions, care plans, and available resources, ensuring that patients can make informed decisions.

Patient Engagement: 

• Uses various strategies, including phone calls, home visits, and community outreach, to engage patients and ensure continuous participation in their care.

Time Management & Organization: 

• Demonstrates strong organizational skills by managing patient caseloads, schedules, and documentation efficiently.

Technology Proficiency: 

• Skilled in using electronic health records (EMR) systems and other digital tools to document patient information and communicate within the team.

Motivational Interviewing & Patient-Centered Care: 

• Uses motivational interviewing techniques to build rapport and empower patients to take ownership of their health decisions.

Data Management: 

• Ensures accurate and timely documentation of patient data, ensuring continuity of care and compliance with organizational standards.

Outcome-Oriented Approach: 

• Focuses on achieving key health outcomes, such as improved care adherence, reduction in emergency room visits, and enhanced self-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. 

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 is a key member of the team responsible for delivering chronic care management to high-complexity patients. The Care Specialist primarily works in patients' homes and communities (90% of the time) and engages in virtual care (10% of the time). This role involves direct outreach to patients, guiding them through the enrollment process, facilitating virtual appointments with providers, and ensuring that patients adhere to care plans. By building relationships, coordinating care, and providing education, the Care Specialist plays a critical role in promoting health, preventing unnecessary hospitalizations, and improving patient outcomes.

Skills Required:

• Minimum of 2 years of relevant work experience (e.g., Community Health Worker, Peer Support Specialist, Medical Assistant, etc.).
• High school diploma or GED required.
• A valid driver’s license, auto liability insurance, and reliable transportation to travel within the assigned territory.
• Experience in chronic care management or working with chronically ill/elderly patients.
• Technologically proficient with basic computer skills (typing, using EMR systems).
• Experience with motivational interviewing, trauma-informed care, and care coordination.
• Strong interpersonal communication skills with the ability to engage patients and team members effectively.
• Ability to prioritize tasks, manage schedules, and work independently in an unstructured environment.
• Multi-lingual skills are a plus but not required.
• Prior home care experience is beneficial.

Key Behaviors:

Adaptability & Resilience: 

• Ability to thrive in unstructured environments and pivot as needed to meet patient needs. Demonstrates perseverance in challenging situations.

Self-Starter & Motivation: 

• Proactively takes initiative in managing patient care and outreach. Willingness to learn and adapt to new processes and systems.

Empathy & Compassion: 

• Ability to work with individuals from diverse backgrounds and understand their complex needs. Skilled in building rapport through motivational interviewing and other patient-centered communication techniques.

Accountability & Integrity: 

• Demonstrates personal responsibility and takes ownership of tasks, ensuring accuracy and timeliness in all activities.

Cultural Competence: 

• Awareness of community dynamics and diversity, ensuring culturally sensitive and inclusive care.

Team Collaboration: 

• Works collaboratively with interdisciplinary teams to meet patient and organizational goals.

Problem-Solving & Critical Thinking: 

• Strong critical thinking skills to assess patient needs, analyze data, and develop appropriate care strategies.

Communication Skills: 

• Excellent verbal and written communication, capable of explaining complex medical information to patients in a clear and supportive manner.

Competencies:

Care Coordination: 

• Ability to engage patients in a comprehensive care plan, facilitating communication between patients, providers, and family members to ensure timely, effective care.

Health Education: 

• Effectively educates patients about their medical conditions, care plans, and available resources, ensuring that patients can make informed decisions.

Patient Engagement: 

• Uses various strategies, including phone calls, home visits, and community outreach, to engage patients and ensure continuous participation in their care.

Time Management & Organization: 

• Demonstrates strong organizational skills by managing patient caseloads, schedules, and documentation efficiently.

Technology Proficiency: 

• Skilled in using electronic health records (EMR) systems and other digital tools to document patient information and communicate within the team.

Motivational Interviewing & Patient-Centered Care: 

• Uses motivational interviewing techniques to build rapport and empower patients to take ownership of their health decisions.

Data Management: 

• Ensures accurate and timely documentation of patient data, ensuring continuity of care and compliance with organizational standards.

Outcome-Oriented Approach: 

• Focuses on achieving key health outcomes, such as improved care adherence, reduction in emergency room visits, and enhanced self-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. 

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 is a key member of the team responsible for delivering chronic care management to high-complexity patients. The Care Specialist primarily works in patients' homes and communities (90% of the time) and engages in virtual care (10% of the time). This role involves direct outreach to patients, guiding them through the enrollment process, facilitating virtual appointments with providers, and ensuring that patients adhere to care plans. By building relationships, coordinating care, and providing education, the Care Specialist plays a critical role in promoting health, preventing unnecessary hospitalizations, and improving patient outcomes.

Skills Required:

• Minimum of 2 years of relevant work experience (e.g., Community Health Worker, Peer Support Specialist, Medical Assistant, etc.).
• High school diploma or GED required.
• A valid driver’s license, auto liability insurance, and reliable transportation to travel within the assigned territory.
• Experience in chronic care management or working with chronically ill/elderly patients.
• Technologically proficient with basic computer skills (typing, using EMR systems).
• Experience with motivational interviewing, trauma-informed care, and care coordination.
• Strong interpersonal communication skills with the ability to engage patients and team members effectively.
• Ability to prioritize tasks, manage schedules, and work independently in an unstructured environment.
• Multi-lingual skills are a plus but not required.
• Prior home care experience is beneficial.

Key Behaviors:

Adaptability & Resilience: 

• Ability to thrive in unstructured environments and pivot as needed to meet patient needs. Demonstrates perseverance in challenging situations.

Self-Starter & Motivation: 

• Proactively takes initiative in managing patient care and outreach. Willingness to learn and adapt to new processes and systems.

Empathy & Compassion: 

• Ability to work with individuals from diverse backgrounds and understand their complex needs. Skilled in building rapport through motivational interviewing and other patient-centered communication techniques.

Accountability & Integrity: 

• Demonstrates personal responsibility and takes ownership of tasks, ensuring accuracy and timeliness in all activities.

Cultural Competence: 

• Awareness of community dynamics and diversity, ensuring culturally sensitive and inclusive care.

Team Collaboration: 

• Works collaboratively with interdisciplinary teams to meet patient and organizational goals.

Problem-Solving & Critical Thinking: 

• Strong critical thinking skills to assess patient needs, analyze data, and develop appropriate care strategies.

Communication Skills: 

• Excellent verbal and written communication, capable of explaining complex medical information to patients in a clear and supportive manner.

Competencies:

Care Coordination: 

• Ability to engage patients in a comprehensive care plan, facilitating communication between patients, providers, and family members to ensure timely, effective care.

Health Education: 

• Effectively educates patients about their medical conditions, care plans, and available resources, ensuring that patients can make informed decisions.

Patient Engagement: 

• Uses various strategies, including phone calls, home visits, and community outreach, to engage patients and ensure continuous participation in their care.

Time Management & Organization: 

• Demonstrates strong organizational skills by managing patient caseloads, schedules, and documentation efficiently.

Technology Proficiency: 

• Skilled in using electronic health records (EMR) systems and other digital tools to document patient information and communicate within the team.

Motivational Interviewing & Patient-Centered Care: 

• Uses motivational interviewing techniques to build rapport and empower patients to take ownership of their health decisions.

Data Management: 

• Ensures accurate and timely documentation of patient data, ensuring continuity of care and compliance with organizational standards.

Outcome-Oriented Approach: 

• Focuses on achieving key health outcomes, such as improved care adherence, reduction in emergency room visits, and enhanced self-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. 

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.

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 is a key member of the team responsible for delivering chronic care management to high-complexity patients. The Care Specialist primarily works in patients' homes and communities (90% of the time) and engages in virtual care (10% of the time). This role involves direct outreach to patients, guiding them through the enrollment process, facilitating virtual appointments with providers, and ensuring that patients adhere to care plans. By building relationships, coordinating care, and providing education, the Care Specialist plays a critical role in promoting health, preventing unnecessary hospitalizations, and improving patient outcomes.

Skills Required:

• Minimum of 2 years of relevant work experience (e.g., Community Health Worker, Peer Support Specialist, Medical Assistant, etc.).
• High school diploma or GED required.
• A valid driver’s license, auto liability insurance, and reliable transportation to travel within the assigned territory.
• Experience in chronic care management or working with chronically ill/elderly patients.
• Technologically proficient with basic computer skills (typing, using EMR systems).
• Experience with motivational interviewing, trauma-informed care, and care coordination.
• Strong interpersonal communication skills with the ability to engage patients and team members effectively.
• Ability to prioritize tasks, manage schedules, and work independently in an unstructured environment.
• Multi-lingual skills are a plus but not required.
• Prior home care experience is beneficial.

Key Behaviors:

Adaptability & Resilience: 

• Ability to thrive in unstructured environments and pivot as needed to meet patient needs. Demonstrates perseverance in challenging situations.

Self-Starter & Motivation: 

• Proactively takes initiative in managing patient care and outreach. Willingness to learn and adapt to new processes and systems.

Empathy & Compassion: 

• Ability to work with individuals from diverse backgrounds and understand their complex needs. Skilled in building rapport through motivational interviewing and other patient-centered communication techniques.

Accountability & Integrity: 

• Demonstrates personal responsibility and takes ownership of tasks, ensuring accuracy and timeliness in all activities.

Cultural Competence: 

• Awareness of community dynamics and diversity, ensuring culturally sensitive and inclusive care.

Team Collaboration: 

• Works collaboratively with interdisciplinary teams to meet patient and organizational goals.

Problem-Solving & Critical Thinking: 

• Strong critical thinking skills to assess patient needs, analyze data, and develop appropriate care strategies.

Communication Skills: 

• Excellent verbal and written communication, capable of explaining complex medical information to patients in a clear and supportive manner.

Competencies:

Care Coordination: 

• Ability to engage patients in a comprehensive care plan, facilitating communication between patients, providers, and family members to ensure timely, effective care.

Health Education: 

• Effectively educates patients about their medical conditions, care plans, and available resources, ensuring that patients can make informed decisions.

Patient Engagement: 

• Uses various strategies, including phone calls, home visits, and community outreach, to engage patients and ensure continuous participation in their care.

Time Management & Organization: 

• Demonstrates strong organizational skills by managing patient caseloads, schedules, and documentation efficiently.

Technology Proficiency: 

• Skilled in using electronic health records (EMR) systems and other digital tools to document patient information and communicate within the team.

Motivational Interviewing & Patient-Centered Care: 

• Uses motivational interviewing techniques to build rapport and empower patients to take ownership of their health decisions.

Data Management: 

• Ensures accurate and timely documentation of patient data, ensuring continuity of care and compliance with organizational standards.

Outcome-Oriented Approach: 

• Focuses on achieving key health outcomes, such as improved care adherence, reduction in emergency room visits, and enhanced self-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. 

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 Community Outreach Specialist (COS) plays a critical role in establishing Upward Health’s presence in the community and reaching potential patients. As the first point of contact for individuals seeking our services, the COS is responsible for educating patients about Upward Health’s offerings, engaging them in meaningful conversations, and facilitating their enrollment into our programs. The COS manages a personal caseload, primarily utilizing phone outreach, but also employing in-person visits and other community-based strategies as needed. This role is essential in ensuring that patients understand the full range of services available to them and helps them take the first steps toward improving their health. The COS reports to the Outreach Manager and works closely with other team members to ensure the overall success of patient outreach and engagement efforts.

Skills Required:

• Strong verbal communication and persuasive abilities
• Excellent interpersonal skills with the ability to build trust and rapport quickly
• Strong organizational and multitasking skills to manage a personal caseload efficiently
• Self-motivated with the ability to work independently and meet outreach goals
• Comfortable with fast-paced environments and adapting outreach methods to various situations
• Proficient in using computer systems for documentation, communication, and managing outreach activities
• Flexible and adaptable to a variety of outreach methods, including phone, in-person meetings, and mailings
• Fluent in English; Spanish proficiency is a plus

Key Behaviors:

Engagement: 

• Proactively builds relationships with potential patients, ensuring they feel informed and supported throughout their journey with Upward Health.

Resilience: 

• Demonstrates the ability to overcome objections and challenges, staying motivated to engage patients even in difficult situations.

Adaptability: 

• Flexibly adjusts outreach strategies based on the needs and preferences of patients, ensuring effective communication at all times.

Team Collaboration: 

• Works well within a team, sharing knowledge, providing support, and contributing to the collective goals of the outreach program.

Efficiency: 

• Effectively manages time to meet outreach goals, balancing a caseload and ensuring timely follow-ups with patients.

Compassion: 

• Approaches patient interactions with empathy, ensuring each patient feels heard and understood.

Cultural Competency: 

• Demonstrates respect for diverse backgrounds and works effectively with individuals from various cultural and socioeconomic backgrounds.

Competencies:

Communication: 

• Ability to clearly and persuasively communicate Upward Health’s services and benefits to potential patients, making complex information easy to understand.

Patient Engagement: 

• Skilled in enrolling patients into Upward Health’s programs and ensuring they have a smooth onboarding experience.

Customer-Centric: 

• Always focused on the needs of the patient, ensuring excellent service throughout the outreach process and helping patients access the right services.

Problem Solving: 

• Capable of addressing patient concerns or objections during outreach efforts, ensuring positive outcomes and maintaining trust.

Time Management: 

• Demonstrates excellent time management by balancing outreach activities, managing caseloads, and meeting set goals within a fast-paced environment.

Data Management: 

• Attention to detail when documenting patient information, ensuring accuracy and timely updates in the company’s systems.

Community Knowledge:

• Familiarity with local resources and the ability to connect patients to additional community-based services that may be beneficial to their care.

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.

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 is a key member of the team responsible for delivering chronic care management to high-complexity patients. The Care Specialist primarily works in patients' homes and communities (90% of the time) and engages in virtual care (10% of the time). This role involves direct outreach to patients, guiding them through the enrollment process, facilitating virtual appointments with providers, and ensuring that patients adhere to care plans. By building relationships, coordinating care, and providing education, the Care Specialist plays a critical role in promoting health, preventing unnecessary hospitalizations, and improving patient outcomes.

Skills Required:

• Minimum of 2 years of relevant work experience (e.g., Community Health Worker, Peer Support Specialist, Medical Assistant, etc.).
• High school diploma or GED required.
• A valid driver’s license, auto liability insurance, and reliable transportation to travel within the assigned territory.
• Experience in chronic care management or working with chronically ill/elderly patients.
• Technologically proficient with basic computer skills (typing, using EMR systems).
• Experience with motivational interviewing, trauma-informed care, and care coordination.
• Strong interpersonal communication skills with the ability to engage patients and team members effectively.
• Ability to prioritize tasks, manage schedules, and work independently in an unstructured environment.
• Multi-lingual skills are a plus but not required.
• Prior home care experience is beneficial.

Key Behaviors:

Adaptability & Resilience: 

• Ability to thrive in unstructured environments and pivot as needed to meet patient needs. Demonstrates perseverance in challenging situations.

Self-Starter & Motivation: 

• Proactively takes initiative in managing patient care and outreach. Willingness to learn and adapt to new processes and systems.

Empathy & Compassion: 

• Ability to work with individuals from diverse backgrounds and understand their complex needs. Skilled in building rapport through motivational interviewing and other patient-centered communication techniques.

Accountability & Integrity: 

• Demonstrates personal responsibility and takes ownership of tasks, ensuring accuracy and timeliness in all activities.

Cultural Competence: 

• Awareness of community dynamics and diversity, ensuring culturally sensitive and inclusive care.

Team Collaboration: 

• Works collaboratively with interdisciplinary teams to meet patient and organizational goals.

Problem-Solving & Critical Thinking: 

• Strong critical thinking skills to assess patient needs, analyze data, and develop appropriate care strategies.

Communication Skills: 

• Excellent verbal and written communication, capable of explaining complex medical information to patients in a clear and supportive manner.

Competencies:

Care Coordination: 

• Ability to engage patients in a comprehensive care plan, facilitating communication between patients, providers, and family members to ensure timely, effective care.

Health Education: 

• Effectively educates patients about their medical conditions, care plans, and available resources, ensuring that patients can make informed decisions.

Patient Engagement: 

• Uses various strategies, including phone calls, home visits, and community outreach, to engage patients and ensure continuous participation in their care.

Time Management & Organization: 

• Demonstrates strong organizational skills by managing patient caseloads, schedules, and documentation efficiently.

Technology Proficiency: 

• Skilled in using electronic health records (EMR) systems and other digital tools to document patient information and communicate within the team.

Motivational Interviewing & Patient-Centered Care: 

• Uses motivational interviewing techniques to build rapport and empower patients to take ownership of their health decisions.

Data Management: 

• Ensures accurate and timely documentation of patient data, ensuring continuity of care and compliance with organizational standards.

Outcome-Oriented Approach: 

• Focuses on achieving key health outcomes, such as improved care adherence, reduction in emergency room visits, and enhanced self-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. 

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.