Chronic Care Navigator — In-Home & Virtual Support

Upward Health; Bridgeport (CT); Hybrid; USD 45,000 - 65,000; Full time

Job summary

Upward Health is an in-home, multidisciplinary medical group providing 24/7 whole-person care. The Care Specialist delivers chronic care management to high-complexity patients, primarily in patients' homes (90%) with some virtual visits (10%).

This role involves direct outreach, enrollment guidance, and coordinating care to improve outcomes. Responsibilities include building relationships, coordinating with providers, educating patients, and ensuring adherence to care plans to prevent

Qualifications

• Minimum of 2 years of relevant work experience (e.g., Community Health Worker, Peer Support Specialist, Medical Assistant).
• 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.

Responsibilities

• Deliver chronic care management to high-complexity patients.
• Work in patients' homes and communities (90%) and engage in virtual care (10%).
• Guide enrollment, facilitate virtual appointments with providers, and ensure adherence to care plans.
• Build relationships, coordinate care, and provide education to promote health and reduce hospitalizations.
• Promote health outcomes through patient-centered communication and care coordination.

Skills

Interpersonal communication

Motivational interviewing

Care coordination

EMR systems

Time management

Independent work

Patient education

Driver's license

Education

High school diploma or GED

Tools

EMR systems

Job description

Upward Health is an in-home, multidisciplinary medical group providing 24/7 whole-person care. The Care Specialist delivers chronic care management to high-complexity patients, primarily in patients' homes (90%) with some virtual visits (10%).

This role involves direct outreach, enrollment guidance, and coordinating care to improve outcomes. Responsibilities include building relationships, coordinating with providers, educating patients, and ensuring adherence to care plans to prevent