Care Specialist - Enhanced Care Management

Upward Health•San Francisco, CA

9d•Hybrid

About The Position

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. 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.

Requirements

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.
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.

Nice To Haves

Multi-lingual capabilities preferred but not required.
Prior home care or Enhanced Care Management experience a plus.
Community Health Worker certification is a plus.

Responsibilities

Coordinate care for high-complexity patients.
Provide chronic care coordination and support, primarily in the field.
Conduct direct outreach to patients via phone calls, home visits, and community interactions.
Assess patient needs and help set health goals.
Ensure patients receive appropriate care and resources.
Focus on increasing access to preventative care, reducing emergency room visits, and enhancing self-management.
Document patient interactions and maintain accurate records in EMR systems.
Educate patients about their health conditions, treatments, and the healthcare system.
Navigate healthcare systems and advocate for needed resources.
Proactively reach out to patients through multiple communication channels.
Work with patients to develop self-care plans, emphasizing shared decision-making.
Work effectively as part of an interdisciplinary care team.
Manage unforeseen challenges and provide support where needed.