Care Specialist

Upward Health•Sacramento, CA

7d•Hybrid

About The Position

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.

Requirements

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.
Awareness of community dynamics and diversity, ensuring culturally sensitive and inclusive care.
Works collaboratively with interdisciplinary teams to meet patient and organizational goals.
Strong critical thinking skills to assess patient needs, analyze data, and develop appropriate care strategies.
Excellent verbal and written communication, capable of explaining complex medical information to patients in a clear and supportive manner.

Nice To Haves

Multi-lingual skills are a plus but not required.
Prior home care experience is beneficial.

Responsibilities

Deliver chronic care management to high-complexity patients.
Work in patients' homes and communities (90% of the time) and engage in virtual care (10% of the time).
Conduct direct outreach to patients.
Guide patients through the enrollment process.
Facilitate virtual appointments with providers.
Ensure patients adhere to care plans.
Build relationships with patients.
Coordinate care.
Provide education to patients.
Promote health.
Prevent unnecessary hospitalizations.
Improve patient outcomes.
Engage patients in a comprehensive care plan.
Facilitate communication between patients, providers, and family members.
Educate patients about their medical conditions, care plans, and available resources.
Use various strategies, including phone calls, home visits, and community outreach, to engage patients.
Ensure continuous participation in patient care.
Manage patient caseloads, schedules, and documentation efficiently.
Use electronic health records (EMR) systems and other digital tools to document patient information and communicate within the team.
Use motivational interviewing techniques to build rapport and empower patients.
Ensure accurate and timely documentation of patient data.
Focus on achieving key health outcomes, such as improved care adherence, reduction in emergency room visits, and enhanced self-management.