Upward Health
Care Specialist - Enhanced Care Management
Upward Health, San Francisco, California, United States, 94199
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 doctors and nurses to Care Specialists and support staff—is driven by a desire to improve the lives of our patients. We treat a wide range of needs and aim to improve access to preventative care, reduce emergency room visits, and enhance self-management. Job Title & Role Description
The Care Specialist - ECM is responsible for coordinating care for high-complexity patients, primarily in the field, providing 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 patients receive the appropriate care and resources. Responsibilities
Coordinate care for high-complexity patients, focusing on increasing access to preventative care, reducing emergency room visits, and enhancing self-management. Conduct outreach to patients via phone, home visits, and community interactions. Assess patient needs, assist with goal setting, and connect patients to appropriate services and resources. Document interactions and outcomes, and manage care plans in collaboration with interdisciplinary teams. Skills & Qualifications
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 ability to travel within the assigned territory or as needed. Experience in care coordination for individuals with chronic conditions, behavioral health conditions, or housing insecurities including homelessness. Strong interpersonal and motivational interviewing skills; ability to build trust and rapport with patients. Familiarity with trauma-informed care, care coordination, and patient education. Proficiency with electronic medical records (EMR) systems and basic computer skills; ability to manage documentation and data entry effectively. Ability to work independently in a field-based environment and as part of a team. Multilingual capabilities preferred but not required. Prior home care or Enhanced Care Management experience is a plus; Community Health Worker certification is a plus. Key Behaviors
Ability to work in dynamic, unstructured environments and pivot to meet patient and organizational needs. Critical Thinking & Problem Solving: assesses patient needs and determines the best course of action. Motivational Interviewing & Empathy: uses techniques to build rapport and empower patients. Relationship Building: establishes trust with patients, families, and team members; proactive outreach and follow-through. Organizational Skills: manages time, tasks, and schedules to address patient needs promptly. Resilience: stays focused on improving patient outcomes in challenging situations. Cultural Competence: provides care that respects diverse cultural backgrounds. Commitment to Quality Care: delivers high-quality care and supports patient well-being and satisfaction. Care Coordination: assesses needs, coordinates services, and navigates healthcare systems to ensure timely access to care. Health Education & Communication: educates patients clearly about conditions, treatments, and the healthcare system. Data Management & Reporting: documents interactions and maintains accurate EMR records. Patient Outreach & Engagement: uses multiple channels to reach patients. Goal Setting & Self-Management: develops shared self-care plans and works within an interdisciplinary team to achieve outcomes. Crisis Management & Flexibility: adapts to unforeseen challenges and supports where needed. Technical Proficiency: skilled in healthcare software and data entry. Compensation
Compensation details: 24-27 Hourly Wage Seniority level
Entry level Employment type
Full-time Job function
Health Care Provider Industries
Hospitals and Health 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.
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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 doctors and nurses to Care Specialists and support staff—is driven by a desire to improve the lives of our patients. We treat a wide range of needs and aim to improve access to preventative care, reduce emergency room visits, and enhance self-management. Job Title & Role Description
The Care Specialist - ECM is responsible for coordinating care for high-complexity patients, primarily in the field, providing 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 patients receive the appropriate care and resources. Responsibilities
Coordinate care for high-complexity patients, focusing on increasing access to preventative care, reducing emergency room visits, and enhancing self-management. Conduct outreach to patients via phone, home visits, and community interactions. Assess patient needs, assist with goal setting, and connect patients to appropriate services and resources. Document interactions and outcomes, and manage care plans in collaboration with interdisciplinary teams. Skills & Qualifications
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 ability to travel within the assigned territory or as needed. Experience in care coordination for individuals with chronic conditions, behavioral health conditions, or housing insecurities including homelessness. Strong interpersonal and motivational interviewing skills; ability to build trust and rapport with patients. Familiarity with trauma-informed care, care coordination, and patient education. Proficiency with electronic medical records (EMR) systems and basic computer skills; ability to manage documentation and data entry effectively. Ability to work independently in a field-based environment and as part of a team. Multilingual capabilities preferred but not required. Prior home care or Enhanced Care Management experience is a plus; Community Health Worker certification is a plus. Key Behaviors
Ability to work in dynamic, unstructured environments and pivot to meet patient and organizational needs. Critical Thinking & Problem Solving: assesses patient needs and determines the best course of action. Motivational Interviewing & Empathy: uses techniques to build rapport and empower patients. Relationship Building: establishes trust with patients, families, and team members; proactive outreach and follow-through. Organizational Skills: manages time, tasks, and schedules to address patient needs promptly. Resilience: stays focused on improving patient outcomes in challenging situations. Cultural Competence: provides care that respects diverse cultural backgrounds. Commitment to Quality Care: delivers high-quality care and supports patient well-being and satisfaction. Care Coordination: assesses needs, coordinates services, and navigates healthcare systems to ensure timely access to care. Health Education & Communication: educates patients clearly about conditions, treatments, and the healthcare system. Data Management & Reporting: documents interactions and maintains accurate EMR records. Patient Outreach & Engagement: uses multiple channels to reach patients. Goal Setting & Self-Management: develops shared self-care plans and works within an interdisciplinary team to achieve outcomes. Crisis Management & Flexibility: adapts to unforeseen challenges and supports where needed. Technical Proficiency: skilled in healthcare software and data entry. Compensation
Compensation details: 24-27 Hourly Wage Seniority level
Entry level Employment type
Full-time Job function
Health Care Provider Industries
Hospitals and Health 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.
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