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 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.