The Medical Director will partner with cross-functional teams and senior leaders to deliver innovative and high-quality care in the home and community for high-need, high-risk, high-utilizing patients. Job requires a leader with a proven track record of innovation, achievement of measurable goals, and exceptional clinical competencies. The candidate has a proactive role in the marketplace and with our patients: delivering care directly and providing clinical oversight to the members of our Interdisciplinary Care Team. The ideal candidate must be flexible and willing to work in an early-stage company on an innovative pilot program solution where the scope of services and protocols will evolve. This is a dynamic environment requiring flexibility, dedication, and commitment to improve care for underserved populations.Upward Health provides technology-enabled, integrated, and coordinated care delivery services that improve outcomes and reduce costs for patients with severe behavioral health diagnoses and co-morbid, chronic physical conditions. We are not your typical medical practice. At Upward Health, we see every day as an opportunity to make a difference in our patients' lives. We could tell you about our outcomes and patient satisfaction ratings. We could tell you about our commitment to our mission, or you could join us and experience it all for yourself. KEY RESPONSIBILITIES:<ul><li>Clinical supervision over care delivery team</li><li>Provide direct collaboration and mentorship for advanced practitioners</li><li>Manage clinical quality audit and peer review process for team clinicians</li><li>Shared accountability with Clinical Operations over patient outcomes, including quality, utilization metrics, and total cost of care</li><li>Partners with Outreach, Operations and Technology to drive service growth, optimization and reliability</li><li>Provide expertise on development and implementation of clinical programs, workflows and best practices</li><li>Lead academic and learning sessions with care team members</li><li>Provider clinical leadership during daily and interdisciplinary patient rounds</li><li>Uphold Medical Affairs agenda and goals for the local market served</li><li>Develop external partnership with PCPs, acute care facilities, and client clinical leadership</li><li>Supports Risk Adjustment Program through evaluation, assessment and training </li><li>Provide direct patient care as required</li></ul> MINIMUM QUALIFICATIONS:<ul><li>Doctor of Medicine degree from a recognized medical school program</li><li>Must possess a current, unrestricted medical license in the State(s) of interest</li><li>Minimum three years of experience practicing in a direct patient care environment, primary care or similar preferred</li><li>Expertise in of population-based medicine and quality improvement principles </li><li>Experience with managing patient with behavioral health and substance use diagnoses is preferred </li><li>Strong healthcare management acumen, including working knowledge of current U. S. payer and provider landscape</li><li>Must be able to positively interact with other clinicians, senior management, patients and their families, and all levels of medical and non-medical professionals</li><li>The high sense of urgency and can-do attitude required </li><li>Strong communication and problem-solving skills - will proactively and thoroughly communicate with other members of the team and seek input and guidance to solve tough problems</li><li>Technical acumen with EMR system (Athena experience a plus</li></ul> 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. PIc5-<img src="https://www.jobg8.com/Tracking.aspx?PcZn9qjsmAyANtWN5GVPhAh" width="0" height="0" />

**Medical Director**

The Medical Director will partner with cross-functional teams and senior leaders to deliver innovative and high-quality care in the home and community for high-need, high-risk, high-utilizing patients. Job requires a leader with a proven track record of innovation, achievement of measurable goals, and exceptional clinical competencies. The candidate has a proactive role in the marketplace and with our patients: delivering care directly and providing clinical oversight to the members of our Interdisciplinary Care Team. The ideal candidate must be flexible and willing to work in an early-stage company on an innovative pilot program solution where the scope of services and protocols will evolve. This is a dynamic environment requiring flexibility, dedication, and commitment to improve care for underserved populations.

Upward Health provides technology-enabled, integrated, and coordinated care delivery services that improve outcomes and reduce costs for patients with severe behavioral health diagnoses and co-morbid, chronic physical conditions. We are not your typical medical practice. At Upward Health, we see every day as an opportunity to make a difference in our patients' lives. We could tell you about our outcomes and patient satisfaction ratings. We could tell you about our commitment to our mission, or you could join us and experience it all for yourself.

**Job Description**

- Clinical supervision over care delivery team
- Provide direct collaboration and mentorship for advanced practitioners
- Manage clinical quality audit and peer review process for team clinicians
- Shared accountability with Clinical Operations over patient outcomes, including quality, utilization metrics, and total cost of care
- Partner with Outreach, Operations, and Technology to drive service growth, optimization, and reliability
- Provide expertise on development and implementation of clinical programs, workflows, and best practices
- Lead academic and learning sessions with care team members
- Provide clinical leadership during daily and interdisciplinary patient rounds
- Uphold Medical Affairs agenda and goals for the local market served
- Develop external partnerships with PCPs, acute care facilities, and client clinical leadership
- Support Risk Adjustment Program through evaluation, assessment, and training
- Provide direct patient care as required

**Requirements**

- Doctor of Medicine degree from a recognized medical school program
- Must possess a current, unrestricted medical license in the State(s) of interest
- Minimum three years of experience practicing in a direct patient care environment, primary care or similar preferred
- Expertise in population-based medicine and quality improvement principles
- Experience managing patients with behavioral health and substance use diagnoses is preferred
- Strong healthcare management acumen, including working knowledge of current U.S. payer and provider landscape
- Must be able to positively interact with other clinicians, senior management, patients and their families, and all levels of medical and non-medical professionals
- High sense of urgency and can-do attitude required
- Strong communication and problem-solving skills - will proactively and thoroughly communicate with other members of the team and seek input and guidance to solve tough problems
- Technical acumen with EMR system (Athena experience a plus)

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.

Medical Director

CARE SPECIALIST Are you a dedicated individual with a passion for providing quality care and making a positive impact in the lives of others? If you possess a unique blend of skills and attributes, including critical thinking, resilience, and the ability to thrive in unstructured environments, we invite you to consider joining our team as a Care Specialist. As a Care Specialist, you will play a crucial role in our organization, working in a dynamic and ever-changing field. Your responsibilities will extend beyond the ordinary, and we are looking for someone who possesses the tenacity, resilience, and perseverance to excel in challenging situations. Your role will require you to be a self-starter, someone who not only understands the art of prioritization but is also keen to understand the "why" behind what we do. You'll engage with individuals from diverse backgrounds and often with complex needs, so the ability to work with difficult people and always be willing to help is a must. You don't just say "no"; you ask "how" and seek the "why." Your awareness of community and diversity will be vital in ensuring that you provide culturally sensitive and inclusive care. Organizational skills, responsiveness, and flexibility are key as you navigate the ever-evolving landscape of healthcare. Your self-motivation and ability to pivot, serving as a change agent when necessary, will be highly valued. You have an outcome-oriented approach and are willing to learn, adapting to new challenges and opportunities with enthusiasm. Criticism doesn't deter you; you take it as a chance for self-improvement and growth. Self-awareness is your ally, and you thrive as an independent problem solver. Your passion for people is the driving force behind your commitment to delivering high-quality care. If you possess these qualities and are ready to embrace a role that demands dedication, adaptability, and a deep desire to make a positive impact, we encourage you to explore the possibilities of becoming a Care Specialist within our organization. Join us in our mission to provide exceptional care and support to those who need it most. Who is Upward Health 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. I t's no wonder 98% of patients report being fully satisfied with Upward Health! What you will do. The Care Specialist works in patient's homes and community 90% of the time and virtually the other 10% to deliver chronic care management to high complexity 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 facilitate virtual visits from the patient's home to our providers remotely to support our integrated care delivery model, 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: <ul><li> Conduct direct outreach to patients via phone, in-person, mailings, and other strategies including cold calling and unscheduled door knocks. </li><li> Enroll patients into Upward Health's program and collect key data about patients during the enrollment process through continuous and on-going phone and in-person interactions. </li><li> Meets patients in their home or in the community to conduct a needs assessment, including helping patients to set health goals. </li><li> Facilitate in-home provider appointments and coordinate care between patients and care team as needed. Ensuring that all of your assigned patients have an initial provider visit and follow up visits scheduled. </li><li> Support your patients in meeting their healthcare goals as it relates to Quality measures. </li><li> Work within an interdisciplinary team to support the team's effort in meeting market and/or organizational goals. </li><li> Obtain and record vital signs and other health information in electronic medical record (EMR) </li><li> Analyze patient data to determine patient needs or treatment goals. </li><li> Assess physical conditions of patients to aid in diagnosis, treatment; and/or need for additional referrals in support of health and social needs. </li><li> Explain technical medical information to educate the patients. </li><li> 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. </li><li> Builds rapport with Upward Health patients utilizing motivational interviewing techniques. </li><li> Conduct one-on-one extended in-person patient appointments. </li><li> Makes follow-up calls and home visits to patients per Upward Health policy. </li><li> Documents each patient encounter with accuracy and precision. </li><li> Prepares reports and documents as needed or requested. </li><li> Attends regular daily huddle, team meetings and participates in clinical rounds. </li><li> Other duties as needed. </li></ul> KNOWLEDGE, SKILLS & ABILITIES: <ul><li> Strong critical thinking skills for assessing patient needs and treatment goals. </li><li> Self-starter with the ability to work independently in an unstructured environment. </li><li> Interpersonal savvy, demonstrated by the ability to interact with and influence people to establish trust and build strong relationships. </li><li> Familiar with concepts like Motivational interviewing, trauma informed care and care coordination. </li><li> Ability to complete unscheduled home visits, completed cold-calls and outreach. </li><li> Strong organization skills and ability to manage and maintain a personal schedule. </li><li> Proficient in time management and the ability to prioritize tasks effectively. </li><li> Ability to work independently within a field-based environment and as part of a team. </li><li> Excellent communication and motivational interviewing skills to engage with difficult patients and the ability to explain technical medical information. </li><li> Proficient in the accurate and timely documentation of patient information in multiple electronic medical record (EMR) systems to ensure seamless continuity of care and data integrity. </li></ul> QUALIFICATIONS: <ul><li> At least 2 years of relevant work experience as a Community Health Worker, Peer Support Specialist, Medical Assistant, or similar role </li><li> High school graduate or GED required. </li><li> A valid driver's license and auto liability insurance. </li><li> Reliable transportation and the ability to travel within your assigned territory or other as needed to support the patient needs plan and training requirements. </li><li> Experience in Chronic Care Management model OR experience with chronically ill/elderly patients. </li><li> Long-time resident of the community with good knowledge of the resources of this community. </li><li> Ability to complete Upward Health's initial training program and ongoing educational requirements as assigned, both virtually and in-person. </li><li> Technologically savvy with basic computer skills, including ability to type. </li><li> Multi-lingual capabilities preferred, but not required. </li><li> Prior Home Care experience a plus </li></ul> 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. PI5a643bd150e8-0451 <img src="https://www.jobg8.com/Tracking.aspx?NjfZMvqqLd99S2kWal2C%2bQj" width="0" height="0" />

**Care Specialist**

Are you a dedicated individual with a passion for providing quality care and making a positive impact in the lives of others? If you possess a unique blend of skills and attributes, including critical thinking, resilience, and the ability to thrive in unstructured environments, we invite you to consider joining our team as a Care Specialist. 

As a Care Specialist, you will play a crucial role in our organization, working in a dynamic and ever-changing field. Your responsibilities will extend beyond the ordinary, and we are looking for someone who possesses the tenacity, resilience, and perseverance to excel in challenging situations. 

Your role will require you to be a self-starter, someone who not only understands the art of prioritization but is also keen to understand the "why" behind what we do. You'll engage with individuals from diverse backgrounds and often with complex needs, so the ability to work with difficult people and always be willing to help is a must. You don't just say "no"; you ask "how" and seek the "why." 

Your awareness of community and diversity will be vital in ensuring that you provide culturally sensitive and inclusive care. Organizational skills, responsiveness, and flexibility are key as you navigate the ever-evolving landscape of healthcare. 

Your self-motivation and ability to pivot, serving as a change agent when necessary, will be highly valued. You have an outcome-oriented approach and are willing to learn, adapting to new challenges and opportunities with enthusiasm. 

Criticism doesn't deter you; you take it as a chance for self-improvement and growth. Self-awareness is your ally, and you thrive as an independent problem solver. Your passion for people is the driving force behind your commitment to delivering high-quality care. 

If you possess these qualities and are ready to embrace a role that demands dedication, adaptability, and a deep desire to make a positive impact, we encourage you to explore the possibilities of becoming a Care Specialist within our organization. Join us in our mission to provide exceptional care and support to those who need it most.

**Who is Upward Health**

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!

**Job Description**

- The Care Specialist works in patients' homes and community 90% of the time and virtually the other 10% to deliver chronic care management to high complexity 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 facilitate virtual visits from the patient's home to our providers remotely to support our integrated care delivery model.
- 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.

**Key Responsibilities**

- Conduct direct outreach to patients via phone, in-person, mailings, and other strategies including cold calling and unscheduled door knocks.
- Enroll patients into Upward Health's program and collect key data about patients during the enrollment process through continuous and ongoing phone and in-person interactions.
- Meet patients in their home or in the community to conduct a needs assessment, including helping patients to set health goals.
- Facilitate in-home provider appointments and coordinate care between patients and care team as needed.
- Support your patients in meeting their healthcare goals as it relates to quality measures.
- Work within an interdisciplinary team to support the team's effort in meeting market and/or organizational goals.
- Obtain and record vital signs and other health information in electronic medical record (EMR).
- 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 educate the patients.
- 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.
- Build rapport with Upward Health patients utilizing motivational interviewing techniques.
- Conduct one-on-one extended in-person patient appointments.
- Make follow-up calls and home visits to patients per Upward Health policy.
- Document each patient encounter with accuracy and precision.
- Prepare reports and documents as needed or requested.
- Attend regular daily huddles, team meetings, and participate in clinical rounds.
- Other duties as needed.

**Knowledge, Skills & Abilities**

- Strong critical thinking skills for assessing patient needs and treatment goals.
- Self-starter with the ability to work independently in an unstructured environment.
- Interpersonal savvy, demonstrated by the ability to interact with and influence people to establish trust and build strong relationships.
- Familiar with concepts like motivational interviewing, trauma-informed care, and care coordination.
- Ability to complete unscheduled home visits, cold-calls, and outreach.
- Strong organization skills and ability to manage and maintain a personal schedule.
- Proficient in time management and the ability to prioritize tasks effectively.
- Ability to work independently within a field-based environment and as part of a team.
- Excellent communication and motivational interviewing skills to engage with difficult patients and the ability to explain technical medical information.
- Proficient in the accurate and timely documentation of patient information in multiple electronic medical record (EMR) systems.

**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.
- 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.
- 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.

Care Specialist

Company 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 our doctors, 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!Job Title & Role Description: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.Skills Required:<ul><li>Minimum of 2 years of relevant work experience (e.g., Community Health Worker, Peer Support Specialist, Medical Assistant, etc.).</li><li>High school diploma or GED required.</li><li>A valid driver's license, auto liability insurance, and reliable transportation to travel within the assigned territory.</li><li>Experience in chronic care management or working with chronically ill/elderly patients.</li><li>Technologically proficient with basic computer skills (typing, using EMR systems).</li><li>Experience with motivational interviewing, trauma-informed care, and care coordination.</li><li>Strong interpersonal communication skills with the ability to engage patients and team members effectively.</li><li>Ability to prioritize tasks, manage schedules, and work independently in an unstructured environment.</li><li>Multi-lingual skills are a plus but not required.</li><li>Prior home care experience is beneficial.</li></ul>Key Behaviors:Adaptability & Resilience: <ul><li>Ability to thrive in unstructured environments and pivot as needed to meet patient needs. Demonstrates perseverance in challenging situations.</li></ul>Self-Starter & Motivation: <ul><li>Proactively takes initiative in managing patient care and outreach. Willingness to learn and adapt to new processes and systems.</li></ul>Empathy & Compassion: <ul><li>Ability to work with individuals from diverse backgrounds and understand their complex needs. Skilled in building rapport through motivational interviewing and other patient-centered communication techniques.</li></ul>Accountability & Integrity: <ul><li>Demonstrates personal responsibility and takes ownership of tasks, ensuring accuracy and timeliness in all activities.</li></ul>Cultural Competence: <ul><li>Awareness of community dynamics and diversity, ensuring culturally sensitive and inclusive care.</li></ul>Team Collaboration: <ul><li>Works collaboratively with interdisciplinary teams to meet patient and organizational goals.</li></ul>Problem-Solving & Critical Thinking: <ul><li>Strong critical thinking skills to assess patient needs, analyze data, and develop appropriate care strategies.</li></ul>Communication Skills: <ul><li>Excellent verbal and written communication, capable of explaining complex medical information to patients in a clear and supportive manner.</li></ul>Competencies:Care Coordination: <ul><li>Ability to engage patients in a comprehensive care plan, facilitating communication between patients, providers, and family members to ensure timely, effective care.</li></ul>Health Education: <ul><li>Effectively educates patients about their medical conditions, care plans, and available resources, ensuring that patients can make informed decisions.</li></ul>Patient Engagement: <ul><li>Uses various strategies, including phone calls, home visits, and community outreach, to engage patients and ensure continuous participation in their care.</li></ul>Time Management & Organization: <ul><li>Demonstrates strong organizational skills by managing patient caseloads, schedules, and documentation efficiently.</li></ul>Technology Proficiency: <ul><li>Skilled in using electronic health records (EMR) systems and other digital tools to document patient information and communicate within the team.</li></ul>Motivational Interviewing & Patient-Centered Care: <ul><li>Uses motivational interviewing techniques to build rapport and empower patients to take ownership of their health decisions.</li></ul>Data Management: <ul><li>Ensures accurate and timely documentation of patient data, ensuring continuity of care and compliance with organizational standards.</li></ul>Outcome-Oriented Approach: <ul><li>Focuses on achieving key health outcomes, such as improved care adherence, reduction in emergency room visits, and enhanced self-management.</li></ul>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. PIbbe138acac69-9994<img src="https://www.jobg8.com/Tracking.aspx?18sjO48iuT2yeqQhwtAwCQa" width="0" height="0" />

**Care Specialist**

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 doctors, 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!

**Job Description**

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

**Key Behaviors**

- **Adaptability & Resilience:** Ability to thrive in unstructured environments and pivot as needed to meet patient needs. Demonstrates perseverance in challenging situations.

- **Self-Starter & Motivation:** Proactively takes initiative in managing patient care and outreach. Willingness to learn and adapt to new processes and systems.

- **Empathy & Compassion:** Ability to work with individuals from diverse backgrounds and understand their complex needs. Skilled in building rapport through motivational interviewing and other patient-centered communication techniques.

- **Accountability & Integrity:** Demonstrates personal responsibility and takes ownership of tasks, ensuring accuracy and timeliness in all activities.

- **Cultural Competence:** Awareness of community dynamics and diversity, ensuring culturally sensitive and inclusive care.

- **Team Collaboration:** Works collaboratively with interdisciplinary teams to meet patient and organizational goals.

- **Problem-Solving & Critical Thinking:** Strong critical thinking skills to assess patient needs, analyze data, and develop appropriate care strategies.

- **Communication Skills:** Excellent verbal and written communication, capable of explaining complex medical information to patients in a clear and supportive manner.

**Competencies**

- **Care Coordination:** Ability to engage patients in a comprehensive care plan, facilitating communication between patients, providers, and family members to ensure timely, effective care.

- **Health Education:** Effectively educates patients about their medical conditions, care plans, and available resources, ensuring that patients can make informed decisions.

- **Patient Engagement:** Uses various strategies, including phone calls, home visits, and community outreach, to engage patients and ensure continuous participation in their care.

- **Time Management & Organization:** Demonstrates strong organizational skills by managing patient caseloads, schedules, and documentation efficiently.

- **Technology Proficiency:** Skilled in using electronic health records (EMR) systems and other digital tools to document patient information and communicate within the team.

- **Motivational Interviewing & Patient-Centered Care:** Uses motivational interviewing techniques to build rapport and empower patients to take ownership of their health decisions.

- **Data Management:** Ensures accurate and timely documentation of patient data, ensuring continuity of care and compliance with organizational standards.

- **Outcome-Oriented Approach:** Focuses on achieving key health outcomes, such as improved care adherence, reduction in emergency room visits, and enhanced self-management.

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.

CARE SPECIALIST - ECM Are you a dedicated individual with a passion for providing quality care and making a positive impact in the lives of others? If you possess a unique blend of skills and attributes, including critical thinking, resilience, and the ability to thrive in unstructured environments, we invite you to consider joining our team as a Care Specialist. As a Care Specialist, you will play a crucial role in our organization, working in a dynamic and ever-changing field. Your responsibilities will extend beyond the ordinary, and we are looking for someone who possesses the tenacity, resilience, and perseverance to excel in challenging situations. Your role will require you to be a self-starter, someone who not only understands the art of prioritization but is also keen to understand the "why" behind what we do. You'll engage with individuals from diverse backgrounds and often with complex needs, so the ability to work with difficult people and always be willing to help is a must. You don't just say "no"; you ask "how" and seek the "why Your awareness of community and diversity will be vital in ensuring that you provide culturally sensitive and inclusive care. Organizational skills, responsiveness, and flexibility are key as you navigate the ever-evolving landscape of healthcare. Your self-motivation and ability to pivot, serving as a change agent when necessary, will be highly valued. You have an outcome-oriented approach and are willing to learn, adapting to new challenges and opportunities with enthusiasm. Criticism doesn't deter you; you take it as a chance for self-improvement and growth. Self-awareness is your ally, and you thrive as an independent problem solver. Your passion for people is the driving force behind your commitment to delivering high-quality care. If you possess these qualities and are ready to embrace a role that demands dedication, adaptability, and a deep desire to make a positive impact, we encourage you to explore the possibilities of becoming a Care Specialist within our organization. Join us in our mission to provide exceptional care and support to those who need it most. Who is Upward Health 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! What you will do. The Care Specialist works in patient's homes and community 90% of the time and virtually the other 10% to deliver chronic care management to high complexity 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 coordinate care from the patient's home or the community to support our integrated care delivery model, 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: <ul><li> Conduct direct outreach to patients via phone, in-person, mailings, and other strategies including cold calling and unscheduled door knocks. </li><li> Enroll patients into Upward Health's program and collect key data about patients during the enrollment process through continuous and on-going phone and in-person interactions. </li><li> Meets patients in their home or in the community to conduct a needs assessment, including helping patients to set health goals. </li><li> Coordinate care between patients and interdisciplinary care teams as needed. </li><li> Support your patients in meeting their healthcare goals as it relates to Quality measures. </li><li> Work within an interdisciplinary team to support the team's effort in meeting market and/or organizational goals. </li><li> Analyze patient data to determine patient needs or treatment goals. </li><li> Assess physical conditions of patients to aid in diagnosis, treatment; and/or need for additional referrals in support of health and social needs. </li><li> Explain technical medical information to educate the patients. </li><li> 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. </li><li> Builds rapport with Upward Health patients utilizing motivational interviewing techniques. </li><li> Conduct one-on-one extended in-person patient appointments. </li><li> Makes follow-up calls and home visits to patients per Upward Health policy. </li><li> Documents each patient encounter with accuracy and precision. </li><li> Prepares reports and documents as needed or requested. </li><li> Attends regular daily huddle, team meetings and participates in clinical rounds. </li><li> Other duties as needed. </li></ul> KNOWLEDGE, SKILLS & ABILITIES: <ul><li> Strong critical thinking skills for assessing patient needs and treatment goals. </li><li> Self-starter with the ability to work independently in an unstructured environment. </li><li> Interpersonal savvy, demonstrated by the ability to interact with and influence people to establish trust and build strong relationships. </li><li> Familiar with concepts like Motivational interviewing, trauma informed care and care coordination. </li><li> Ability to complete unscheduled home visits, completed cold-calls and outreach. </li><li> Strong organization skills and ability to manage and maintain a personal schedule. </li><li> Proficient in time management and the ability to prioritize tasks effectively. </li><li> Ability to work independently within a field-based environment and as part of a team. </li><li> Excellent communication and motivational interviewing skills to engage with difficult patients and the ability to explain technical medical information. </li><li> Proficient in the accurate and timely documentation of patient information in multiple electronic medical record (EMR) systems to ensure seamless continuity of care and data integrity. </li></ul> QUALIFICATIONS: <ul><li> At least 2 years of relevant work experience as a Community Health Worker, Peer Support Specialist, Medical Assistant, or similar role </li><li> High school graduate or GED required. </li><li> A valid driver's license and auto liability insurance. </li><li> Reliable transportation and the ability to travel within your assigned territory or other as needed to support the patient needs plan and training requirements. </li><li> Experience in Chronic Care Management model OR experience with chronically ill/elderly patients. </li><li> Long-time resident of the community with good knowledge of the resources of this community. </li><li> Ability to complete Upward Health's initial training program and ongoing educational requirements as assigned, both virtually and in-person. </li><li> Technologically savvy with basic computer skills, including ability to type. </li><li> Multi-lingual capabilities preferred, but not required. </li><li> Prior Home Care experience a plus </li></ul> 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. Compensation details: 24-27 Hourly Wage PI38dcc5-<img src="https://www.jobg8.com/Tracking.aspx?NjfZMvqqLd%2bP1Q1w4q03vwj" width="0" height="0" />

**Care Specialist - ECM**

Are you a dedicated individual with a passion for providing quality care and making a positive impact in the lives of others? If you possess a unique blend of skills and attributes, including critical thinking, resilience, and the ability to thrive in unstructured environments, we invite you to consider joining our team as a Care Specialist.

As a Care Specialist, you will play a crucial role in our organization, working in a dynamic and ever-changing field. Your responsibilities will extend beyond the ordinary, and we are looking for someone who possesses the tenacity, resilience, and perseverance to excel in challenging situations.

Your role will require you to be a self-starter, someone who not only understands the art of prioritization but is also keen to understand the "why" behind what we do. You'll engage with individuals from diverse backgrounds and often with complex needs, so the ability to work with difficult people and always be willing to help is a must. You don't just say "no"; you ask "how" and seek the "why."

Your awareness of community and diversity will be vital in ensuring that you provide culturally sensitive and inclusive care. Organizational skills, responsiveness, and flexibility are key as you navigate the ever-evolving landscape of healthcare.

Your self-motivation and ability to pivot, serving as a change agent when necessary, will be highly valued. You have an outcome-oriented approach and are willing to learn, adapting to new challenges and opportunities with enthusiasm.

Criticism doesn't deter you; you take it as a chance for self-improvement and growth. Self-awareness is your ally, and you thrive as an independent problem solver. Your passion for people is the driving force behind your commitment to delivering high-quality care.

If you possess these qualities and are ready to embrace a role that demands dedication, adaptability, and a deep desire to make a positive impact, we encourage you to explore the possibilities of becoming a Care Specialist within our organization. Join us in our mission to provide exceptional care and support to those who need it most.

**Who is Upward Health**

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!

**Job Description**

- The Care Specialist works in patients' homes and community 90% of the time and virtually the other 10% to deliver chronic care management to high complexity 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 coordinate care from the patient's home or the community to support our integrated care delivery model, 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 healthcare costs

**Key Responsibilities**

- Conduct direct outreach to patients via phone, in-person, mailings, and other strategies including cold calling and unscheduled door knocks.
- Enroll patients into Upward Health's program and collect key data about patients during the enrollment process through continuous and ongoing phone and in-person interactions.
- Meet 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 interdisciplinary care teams as needed.
- Support your patients in meeting their healthcare goals as it relates to quality measures.
- Work within an interdisciplinary team to support the team's effort in meeting market and/or organizational goals.
- 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 educate the patients.
- 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.
- Build rapport with Upward Health patients utilizing motivational interviewing techniques.
- Conduct one-on-one extended in-person patient appointments.
- Make follow-up calls and home visits to patients per Upward Health policy.
- Document each patient encounter with accuracy and precision.
- Prepare reports and documents as needed or requested.
- Attend regular daily huddles, team meetings, and participate in clinical rounds.
- Other duties as needed.

**Knowledge, Skills & Abilities**

- Strong critical thinking skills for assessing patient needs and treatment goals.
- Self-starter with the ability to work independently in an unstructured environment.
- Interpersonal savvy, demonstrated by the ability to interact with and influence people to establish trust and build strong relationships.
- Familiar with concepts like motivational interviewing, trauma-informed care, and care coordination.
- Ability to complete unscheduled home visits, cold calls, and outreach.
- Strong organization skills and ability to manage and maintain a personal schedule.
- Proficient in time management and the ability to prioritize tasks effectively.
- Ability to work independently within a field-based environment and as part of a team.
- Excellent communication and motivational interviewing skills to engage with difficult patients and the ability to explain technical medical information.
- Proficient in the accurate and timely documentation of patient information in multiple electronic medical record (EMR) systems to ensure seamless continuity of care and data integrity.

**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.
- 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.
- Multi-lingual capabilities preferred but not required.
- Prior home care experience a plus.

**Compensation Details**

24-27 Hourly Wage

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.

Care Specialist - Enhanced Care Management

CARE SPECIALIST - ECM Are you a dedicated individual with a passion for providing quality care and making a positive impact in the lives of others? If you possess a unique blend of skills and attributes, including critical thinking, resilience, and the ability to thrive in unstructured environments, we invite you to consider joining our team as a Care Specialist. As a Care Specialist, you will play a crucial role in our organization, working in a dynamic and ever-changing field. Your responsibilities will extend beyond the ordinary, and we are looking for someone who possesses the tenacity, resilience, and perseverance to excel in challenging situations. Your role will require you to be a self-starter, someone who not only understands the art of prioritization but is also keen to understand the "why" behind what we do. You'll engage with individuals from diverse backgrounds and often with complex needs, so the ability to work with difficult people and always be willing to help is a must. You don't just say "no"; you ask "how" and seek the "why Your awareness of community and diversity will be vital in ensuring that you provide culturally sensitive and inclusive care. Organizational skills, responsiveness, and flexibility are key as you navigate the ever-evolving landscape of healthcare. Your self-motivation and ability to pivot, serving as a change agent when necessary, will be highly valued. You have an outcome-oriented approach and are willing to learn, adapting to new challenges and opportunities with enthusiasm. Criticism doesn't deter you; you take it as a chance for self-improvement and growth. Self-awareness is your ally, and you thrive as an independent problem solver. Your passion for people is the driving force behind your commitment to delivering high-quality care. If you possess these qualities and are ready to embrace a role that demands dedication, adaptability, and a deep desire to make a positive impact, we encourage you to explore the possibilities of becoming a Care Specialist within our organization. Join us in our mission to provide exceptional care and support to those who need it most. Who is Upward Health 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! What you will do. The Care Specialist works in patient's homes and community 90% of the time and virtually the other 10% to deliver chronic care management to high complexity 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 coordinate care from the patient's home or the community to support our integrated care delivery model, 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: <ul><li> Conduct direct outreach to patients via phone, in-person, mailings, and other strategies including cold calling and unscheduled door knocks. </li><li> Enroll patients into Upward Health's program and collect key data about patients during the enrollment process through continuous and on-going phone and in-person interactions. </li><li> Meets patients in their home or in the community to conduct a needs assessment, including helping patients to set health goals. </li><li> Coordinate care between patients and interdisciplinary care teams as needed. </li><li> Support your patients in meeting their healthcare goals as it relates to Quality measures. </li><li> Work within an interdisciplinary team to support the team's effort in meeting market and/or organizational goals. </li><li> Analyze patient data to determine patient needs or treatment goals. </li><li> Assess physical conditions of patients to aid in diagnosis, treatment; and/or need for additional referrals in support of health and social needs. </li><li> Explain technical medical information to educate the patients. </li><li> 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. </li><li> Builds rapport with Upward Health patients utilizing motivational interviewing techniques. </li><li> Conduct one-on-one extended in-person patient appointments. </li><li> Makes follow-up calls and home visits to patients per Upward Health policy. </li><li> Documents each patient encounter with accuracy and precision. </li><li> Prepares reports and documents as needed or requested. </li><li> Attends regular daily huddle, team meetings and participates in clinical rounds. </li><li> Other duties as needed. </li></ul> KNOWLEDGE, SKILLS & ABILITIES: <ul><li> Strong critical thinking skills for assessing patient needs and treatment goals. </li><li> Self-starter with the ability to work independently in an unstructured environment. </li><li> Interpersonal savvy, demonstrated by the ability to interact with and influence people to establish trust and build strong relationships. </li><li> Familiar with concepts like Motivational interviewing, trauma informed care and care coordination. </li><li> Ability to complete unscheduled home visits, completed cold-calls and outreach. </li><li> Strong organization skills and ability to manage and maintain a personal schedule. </li><li> Proficient in time management and the ability to prioritize tasks effectively. </li><li> Ability to work independently within a field-based environment and as part of a team. </li><li> Excellent communication and motivational interviewing skills to engage with difficult patients and the ability to explain technical medical information. </li><li> Proficient in the accurate and timely documentation of patient information in multiple electronic medical record (EMR) systems to ensure seamless continuity of care and data integrity. </li></ul> QUALIFICATIONS: <ul><li> At least 2 years of relevant work experience as a Community Health Worker, Peer Support Specialist, Medical Assistant, or similar role </li><li> High school graduate or GED required. </li><li> A valid driver's license and auto liability insurance. </li><li> Reliable transportation and the ability to travel within your assigned territory or other as needed to support the patient needs plan and training requirements. </li><li> Experience in Chronic Care Management model OR experience with chronically ill/elderly patients. </li><li> Long-time resident of the community with good knowledge of the resources of this community. </li><li> Ability to complete Upward Health's initial training program and ongoing educational requirements as assigned, both virtually and in-person. </li><li> Technologically savvy with basic computer skills, including ability to type. </li><li> Multi-lingual capabilities preferred, but not required. </li><li> Prior Home Care experience a plus </li></ul> 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. Compensation details: 24-27 Hourly Wage PIc99b98ccc5-<img src="https://www.jobg8.com/Tracking.aspx?8vtR65FWeb8u1nahAvsAigg" width="0" height="0" />

Company 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 our doctors, 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!Job Title & Role Description:The Nurse Care Manager is a field-based role responsible for care coordination of high-risk patients who require comprehensive care plans addressing chronic conditions. The Nurse Care Manager works with a multidisciplinary Care Team, collaborating to ensure optimal health outcomes for patients through personalized care plans, self-management, and disease prevention. This role focuses on chronic care management and care transitions, particularly for patients discharged from inpatient settings, and involves both in-person and telephonic outreach, medication reconciliation, and ensuring continuity of care across the healthcare ecosystem. The Nurse Care Manager acts as an advocate for patients and ensures the integration of services across providers, hospitals, and outpatient services.Skills Required:<ul><li>Registered nursing license (unrestricted)</li><li>Expertise in care management and coordination across healthcare providers</li><li>Strong communication skills for patient and caregiver education</li><li>Ability to conduct both in-home and telephonic assessments, care plans, and medication reconciliations</li><li>Experience with EHR systems and real-time documentation</li><li>Ability to work independently and manage multiple patient cases</li><li>Critical thinking and decision-making skills in developing care plans</li><li>Proficient in using digital tools for care coordination and communication</li><li>A valid driver's license and auto liability insurance</li><li>Reliable transportation and the ability to travel within assigned territory or as needed</li><li>Case management certification is a plus but not required</li></ul> Key Behaviors:Patient-Centered Care:<ul><li>Develops strong relationships with patients and caregivers, advocating for their needs and ensuring they understand and follow their care plans.</li></ul>Collaboration: <ul><li>Works effectively with the multidisciplinary Care Team Pod to ensure seamless care across all providers and services.</li></ul>Proactive Communication: <ul><li>Actively reaches out to patients and caregivers within 48 hours of discharge to ensure smooth transitions and minimize gaps in care.</li></ul>Advocacy and Education: <ul><li>Provides clear, compassionate education to patients and families about treatment options and ensures patients are empowered to manage their health.</li></ul>Care Coordination: <ul><li>Ensures that care is effectively coordinated across multiple providers, institutions, and services, particularly during transitions of care.</li></ul>Time Management: <ul><li>Effectively manages patient caseloads, balancing multiple tasks while adhering to deadlines and care plans.</li></ul>Problem Solving: <ul><li>Identifies potential gaps in care, resolves issues through collaboration with providers, and works to optimize patient outcomes.</li></ul>Confidentiality: <ul><li>Maintains patient confidentiality and follows HIPAA regulations to ensure privacy in all interactions.</li></ul>Cultural Competence: <ul><li>Demonstrates respect for diversity, ensuring culturally sensitive care that meets the needs of diverse patient populations.</li></ul>Competencies:Clinical Expertise: <ul><li>Strong knowledge of chronic disease management, care transitions, and evidence-based practices to develop and implement care plans.</li></ul>Effective Communication: <ul><li>Skilled at delivering complex medical information clearly to patients, caregivers, and interdisciplinary teams.</li></ul>Care Plan Development: <ul><li>Proficient in creating personalized care plans that address physical, behavioral, and social health needs.</li></ul>Technology Proficiency: <ul><li>Ability to use electronic health records (EHR) and care management systems to document, track, and coordinate patient care.</li></ul>Outcome-Oriented: <ul><li>Focused on achieving optimal clinical and financial outcomes for patients through effective care coordination and management.</li></ul>Independent and Team-Oriented: <ul><li>Able to work independently in a remote environment while also collaborating effectively with a multidisciplinary team.</li></ul>Critical Thinking: <ul><li>Uses clinical judgment to assess, analyze, and evaluate patient progress, adapting care plans as needed to achieve optimal results.</li></ul>Multitasking and Prioritization: <ul><li>Manages multiple patient cases simultaneously while prioritizing tasks to meet deadlines and ensure comprehensive care.</li></ul>Patient Engagement: <ul><li>Motivates patients to follow care plans and improve self-care skills through regular communication and support.</li></ul> 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. Compensation details: 00 Yearly Salary PIaeff60dadec8-2761<img src="https://www.jobg8.com/Tracking.aspx?PcZn9qjsmAyqH%2fJOB5p5vgh" width="0" height="0" />

**Nurse Care Manager**

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 doctors, 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!

**Job Description**

- The Nurse Care Manager is a field-based role responsible for care coordination of high-risk patients who require comprehensive care plans addressing chronic conditions.
- The Nurse Care Manager works with a multidisciplinary Care Team, collaborating to ensure optimal health outcomes for patients through personalized care plans, self-management, and disease prevention.
- This role focuses on chronic care management and care transitions, particularly for patients discharged from inpatient settings, and involves both in-person and telephonic outreach, medication reconciliation, and ensuring continuity of care across the healthcare ecosystem.
- The Nurse Care Manager acts as an advocate for patients and ensures the integration of services across providers, hospitals, and outpatient services.

**Requirements**

- Registered nursing license (unrestricted)
- Expertise in care management and coordination across healthcare providers
- Strong communication skills for patient and caregiver education
- Ability to conduct both in-home and telephonic assessments, care plans, and medication reconciliations
- Experience with EHR systems and real-time documentation
- Ability to work independently and manage multiple patient cases
- Critical thinking and decision-making skills in developing care plans
- Proficient in using digital tools for care coordination and communication
- A valid driver's license and auto liability insurance
- Reliable transportation and the ability to travel within assigned territory or as needed
- Case management certification is a plus but not required

**Key Behaviors**

- **Patient-Centered Care:** Develops strong relationships with patients and caregivers, advocating for their needs and ensuring they understand and follow their care plans.

- **Collaboration:** Works effectively with the multidisciplinary Care Team Pod to ensure seamless care across all providers and services.

- **Proactive Communication:** Actively reaches out to patients and caregivers within 48 hours of discharge to ensure smooth transitions and minimize gaps in care.

- **Advocacy and Education:** Provides clear, compassionate education to patients and families about treatment options and ensures patients are empowered to manage their health.

- **Care Coordination:** Ensures that care is effectively coordinated across multiple providers, institutions, and services, particularly during transitions of care.

- **Time Management:** Effectively manages patient caseloads, balancing multiple tasks while adhering to deadlines and care plans.

- **Problem Solving:** Identifies potential gaps in care, resolves issues through collaboration with providers, and works to optimize patient outcomes.

- **Confidentiality:** Maintains patient confidentiality and follows HIPAA regulations to ensure privacy in all interactions.

- **Cultural Competence:** Demonstrates respect for diversity, ensuring culturally sensitive care that meets the needs of diverse patient populations.

**Competencies**

- **Clinical Expertise:** Strong knowledge of chronic disease management, care transitions, and evidence-based practices to develop and implement care plans.

- **Effective Communication:** Skilled at delivering complex medical information clearly to patients, caregivers, and interdisciplinary teams.

- **Care Plan Development:** Proficient in creating personalized care plans that address physical, behavioral, and social health needs.

- **Technology Proficiency:** Ability to use electronic health records (EHR) and care management systems to document, track, and coordinate patient care.

- **Outcome-Oriented:** Focused on achieving optimal clinical and financial outcomes for patients through effective care coordination and management.

- **Independent and Team-Oriented:** Able to work independently in a remote environment while also collaborating effectively with a multidisciplinary team.

- **Critical Thinking:** Uses clinical judgment to assess, analyze, and evaluate patient progress, adapting care plans as needed to achieve optimal results.

- **Multitasking and Prioritization:** Manages multiple patient cases simultaneously while prioritizing tasks to meet deadlines and ensure comprehensive care.

- **Patient Engagement:** Motivates patients to follow care plans and improve self-care skills through regular communication and support.

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.

**Compensation Details**

00 Yearly Salary

Nurse Care Manager

Company 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 our doctors, 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!Job Title & Role Description:The Nurse Care Manager is a field-based role responsible for care coordination of high-risk patients who require comprehensive care plans addressing chronic conditions. The Nurse Care Manager works with a multidisciplinary Care Team, collaborating to ensure optimal health outcomes for patients through personalized care plans, self-management, and disease prevention. This role focuses on chronic care management and care transitions, particularly for patients discharged from inpatient settings, and involves both in-person and telephonic outreach, medication reconciliation, and ensuring continuity of care across the healthcare ecosystem. The Nurse Care Manager acts as an advocate for patients and ensures the integration of services across providers, hospitals, and outpatient services.Skills Required:<ul><li>Registered nursing license (unrestricted)</li><li>Expertise in care management and coordination across healthcare providers</li><li>Strong communication skills for patient and caregiver education</li><li>Ability to conduct both in-home and telephonic assessments, care plans, and medication reconciliations</li><li>Experience with EHR systems and real-time documentation</li><li>Ability to work independently and manage multiple patient cases</li><li>Critical thinking and decision-making skills in developing care plans</li><li>Proficient in using digital tools for care coordination and communication</li><li>A valid driver's license and auto liability insurance</li><li>Reliable transportation and the ability to travel within assigned territory or as needed</li><li>Case management certification is a plus but not required</li></ul> Key Behaviors:Patient-Centered Care:<ul><li>Develops strong relationships with patients and caregivers, advocating for their needs and ensuring they understand and follow their care plans.</li></ul>Collaboration: <ul><li>Works effectively with the multidisciplinary Care Team Pod to ensure seamless care across all providers and services.</li></ul>Proactive Communication: <ul><li>Actively reaches out to patients and caregivers within 48 hours of discharge to ensure smooth transitions and minimize gaps in care.</li></ul>Advocacy and Education: <ul><li>Provides clear, compassionate education to patients and families about treatment options and ensures patients are empowered to manage their health.</li></ul>Care Coordination: <ul><li>Ensures that care is effectively coordinated across multiple providers, institutions, and services, particularly during transitions of care.</li></ul>Time Management: <ul><li>Effectively manages patient caseloads, balancing multiple tasks while adhering to deadlines and care plans.</li></ul>Problem Solving: <ul><li>Identifies potential gaps in care, resolves issues through collaboration with providers, and works to optimize patient outcomes.</li></ul>Confidentiality: <ul><li>Maintains patient confidentiality and follows HIPAA regulations to ensure privacy in all interactions.</li></ul>Cultural Competence: <ul><li>Demonstrates respect for diversity, ensuring culturally sensitive care that meets the needs of diverse patient populations.</li></ul>Competencies:Clinical Expertise: <ul><li>Strong knowledge of chronic disease management, care transitions, and evidence-based practices to develop and implement care plans.</li></ul>Effective Communication: <ul><li>Skilled at delivering complex medical information clearly to patients, caregivers, and interdisciplinary teams.</li></ul>Care Plan Development: <ul><li>Proficient in creating personalized care plans that address physical, behavioral, and social health needs.</li></ul>Technology Proficiency: <ul><li>Ability to use electronic health records (EHR) and care management systems to document, track, and coordinate patient care.</li></ul>Outcome-Oriented: <ul><li>Focused on achieving optimal clinical and financial outcomes for patients through effective care coordination and management.</li></ul>Independent and Team-Oriented: <ul><li>Able to work independently in a remote environment while also collaborating effectively with a multidisciplinary team.</li></ul>Critical Thinking: <ul><li>Uses clinical judgment to assess, analyze, and evaluate patient progress, adapting care plans as needed to achieve optimal results.</li></ul>Multitasking and Prioritization: <ul><li>Manages multiple patient cases simultaneously while prioritizing tasks to meet deadlines and ensure comprehensive care.</li></ul>Patient Engagement: <ul><li>Motivates patients to follow care plans and improve self-care skills through regular communication and support.</li></ul> 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. Compensation details: 00 Yearly Salary PI2d37715acce9-2775<img src="https://www.jobg8.com/Tracking.aspx?s9C9mpSRxCipMiGOJ%2fs4Rgi" width="0" height="0" />

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