Chronic Care Coordinator — Home Visits

Upward Health, Inc.; Albuquerque (NM); Remote; USD 42,000 - 62,000; Full time

Job summary

Upward Health, Inc. is seeking a Care Specialist to deliver chronic care management for high-complexity patients. The role is primarily in patients\' homes, with some virtual care, focusing on enrollment, care coordination, and education to improve outcomes.

You will build relationships, coordinate care with providers, and support patients in adhering to care plans. Strong communication and independence in unstructured environments are essential to succeed.

Qualifications

• 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.

Responsibilities

• Deliver chronic care management to high-complexity patients, primarily in patients' homes (90%) and virtually (10%).
• Guide patients through enrollment and facilitate virtual appointments with providers.
• Coordinate care, build relationships, and educate patients to promote health and reduce hospitalizations.

Skills

Interpersonal communication

Motivational interviewing

Trauma-informed care

Care coordination

Time management

Organization

Independent work

Multilingual

Empathy

Technology proficiency

Education

High school diploma or GED

Tools

EMR systems

Job description

Upward Health, Inc. is seeking a Care Specialist to deliver chronic care management for high-complexity patients. The role is primarily in patients\' homes, with some virtual care, focusing on enrollment, care coordination, and education to improve outcomes.

You will build relationships, coordinate care with providers, and support patients in adhering to care plans. Strong communication and independence in unstructured environments are essential to succeed.