Care Specialist Community Health Worker

COMMUNITY HEALTH WORKER

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 providers, 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!

WHY IS THIS ROLE CRITICAL?

The Community Health Worker (also referred to as a Care Specialist) works in patient’s homes, wherever they call home, to deliver chronic care management to high complexity patients. This position is the first point of contact with our company for our patients. We count on the Care Specialist to make an excellent first impression and to be able to effectively communicate our service offering to patients. During initial outreach the Care Specialist informs patients about our services and helps them get enrolled. Reaching out via phone is our top strategy for outreach and it’s important that the Care Specialist is comfortable and confident communicating by phone. Field-based approaches are utilized as well, and the Care Specialist should be prepared to use whatever strategy is most effective. Once the patient is enrolled, the Care Specialist will primarily be focused on the following goals: Promote timely access to appropriate care; increase utilization of preventative care; reduce emergency room utilization and hospital readmissions; create and promote adherence to a care plan developed in coordination with the patient, primary care provider, and family/caregiver(s); increase patient’s ability for self-management and shared decision-making; provide medication reconciliation; connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costs

KEY RESPONSIBILITIES:

• Conduct direct outreach to patients via phone, in-person, mailings, and other strategies.
• Speak with patients about the role that Upward Health can play in helping them improve their health.
• Enroll patients into Upward Health’s program and collect key data about patients during the enrollment process.
• Meets patients in their home or in the community to conduct a needs assessment, including helping patients to set health goals.
• Coordinate care between patients and care team as needed.
• Monitor patients to detect health problems.
• Analyze patient data to determine patient needs or treatment goals.
• Assess physical conditions of patients to aid in diagnosis, treatment; and/or need for additional referrals in support of health and social needs.
• Explain technical medical information to patients.
• Collect medical information from patients, family members, or other medical professionals.
• Operate medical equipment (glucometer, electronic devices for V.S. monitoring).
• Cultivate and support the primary care providers with timely communication, inquiry follow-up, and integration of information into the care plan regarding transitions-in-care and referral.
• Builds rapport with Upward Health patients utilizing motivational interviewing techniques.
• Conduct one-on-one extended patient calls for initial care plans, follow-up with patients, family/caregiver(s), providers, and community resources via secure e-mail, phone calls, and other communications
• Makes follow-up calls and home visits to patients per Upward Health policy.
• Documents each patient encounter in detail per Upward Health Policies.
• Prepares reports and documents as needed or requested.
• Attends regular team meetings and participate in clinical rounds.
• Other duties as needed.

KNOWLEDGE, SKILLS & ABILITIES:

• Interpersonal savvy, demonstrated by the ability to interact with and influence people to establish trust and build strong relationships.
• Ability to do home and community visits and outreach.
• Experience with usage of EMR/EHRs.
• Experience working in a high-volume physician practice, hospital setting, or possibly a home care role.
• Strong organization skills and ability to manage and maintain a personal schedule.
• Ability to establish priorities and meet deadlines.
• Ability to work independently within a virtual operating environment and as part of a team.
• Excellent oral and written communication skills.
• Ability to exercise judgment in the application of professional services.
• Active listening skills and genuine compassion for others.
• Able to maintain clear professional boundaries with patients and coworkers.
• Commitment to represent the company with professionalism.
• Demonstrates cultural competency and ability to work with diverse groups of community members.
• Comfortable using computer for documentation, communication, and organizing work.

QUALIFICATIONS:

• At least 2 years of relevant work experience as a Community Health Worker, Peer Support Specialist, Medical Assistant, or similar role
• High school graduate or GED required.
• A valid driver’s license and auto liability insurance.
• Reliable transportation and the ability to travel within your assigned territory or other as needed to support the patient needs plan and training requirements.
• Experience in Chronic Care Management model OR experience with chronically ill/elderly patients.
• Long-time resident of the community with good knowledge of the resources of this community.
• Able to maintain clear professional boundaries with members and coworkers.
• Ability to complete Upward Health’s initial training program and ongoing educational requirements as assigned, both virtually and in-person.
• Technologically savvy with basic computer skills, including ability to type.
• Strong communication and problem-solving skills
• Multi-lingual capabilities preferred, but not required.
• Prior Home Care experience a plus

Upward Health is proud to be an equal opportunity/affirmative action 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.