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. We are driven by a desire to improve the lives of our patients and are proud to be an equal opportunity employer. Job Title & Role Description:
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. Responsibilities
Coordinate care for high-complexity patients, primarily in field settings. Perform outreach to patients via phone, home visits, and community interactions. Assess patient needs, set health goals, and link patients to appropriate care and resources. Increase access to preventative care, reduce emergency department visits, and enhance patient self-management. Work independently in a field-based environment and as part of an interdisciplinary team. 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 the ability to travel within 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 to build trust and rapport with patients. Familiarity with trauma-informed care, care coordination, and patient education. Proficiency in 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
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: Establishes trust and fosters strong relationships with patients, families, and team members; takes initiative to perform outreach, complete assessments, and coordinate care. Organizational Skills: Manages time, tasks, and schedules to ensure patient needs are addressed promptly. Resilience: Maintains focus on improving patient outcomes in challenging situations. Cultural Competence: Provides culturally inclusive care. Commitment to Quality Care: Delivers high-quality care and support to patients. Care Coordination: Assesses patient needs and coordinates care with interdisciplinary teams; navigates healthcare systems to ensure timely access to services. Health Education & Communication: Educates patients about health conditions, treatments, and the healthcare system clearly and empathetically. Data Management & Reporting: Documents patient interactions and maintains accurate records in EMR systems. Patient Outreach & Engagement: Proactively reaches out to patients through multiple channels. Goal Setting & Self-Management: Helps patients develop self-care plans and supports shared decision-making. Crisis Management & Flexibility: Adapts to unforeseen challenges to support patient needs. Technical Proficiency: Uses healthcare software for data entry and patient management. Compensation
Compensation details:
24-27 Hourly Wage Job Details
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. We are driven by a desire to improve the lives of our patients and are proud to be an equal opportunity employer. Job Title & Role Description:
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. Responsibilities
Coordinate care for high-complexity patients, primarily in field settings. Perform outreach to patients via phone, home visits, and community interactions. Assess patient needs, set health goals, and link patients to appropriate care and resources. Increase access to preventative care, reduce emergency department visits, and enhance patient self-management. Work independently in a field-based environment and as part of an interdisciplinary team. 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 the ability to travel within 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 to build trust and rapport with patients. Familiarity with trauma-informed care, care coordination, and patient education. Proficiency in 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
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: Establishes trust and fosters strong relationships with patients, families, and team members; takes initiative to perform outreach, complete assessments, and coordinate care. Organizational Skills: Manages time, tasks, and schedules to ensure patient needs are addressed promptly. Resilience: Maintains focus on improving patient outcomes in challenging situations. Cultural Competence: Provides culturally inclusive care. Commitment to Quality Care: Delivers high-quality care and support to patients. Care Coordination: Assesses patient needs and coordinates care with interdisciplinary teams; navigates healthcare systems to ensure timely access to services. Health Education & Communication: Educates patients about health conditions, treatments, and the healthcare system clearly and empathetically. Data Management & Reporting: Documents patient interactions and maintains accurate records in EMR systems. Patient Outreach & Engagement: Proactively reaches out to patients through multiple channels. Goal Setting & Self-Management: Helps patients develop self-care plans and supports shared decision-making. Crisis Management & Flexibility: Adapts to unforeseen challenges to support patient needs. Technical Proficiency: Uses healthcare software for data entry and patient management. Compensation
Compensation details:
24-27 Hourly Wage Job Details
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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