Home-Based Care Specialist — Chronic Care Advocate

Upward Health; Hartford (CT); On-site; USD 29,000 - 34,000; Full time

Job summary

Upward Health specializes in in-home, multidisciplinary care, delivering 24/7 whole-person services across physical, behavioral, and social health needs. The Care Specialist leads chronic care management for high‑complexity patients, primarily in home settings with some virtual visits, guiding enrollment and coordinating with providers.

The role emphasizes building relationships, patient education, adherence to care plans, and reducing hospitalizations while improving outcomes through proactive

Qualifications

• Minimum 2 years of relevant work experience in community health or care roles.
• High school diploma or GED required.
• Valid driver’s license and reliable transportation within territory.
• Experience in chronic care management or with chronically ill/elderly patients.
• Proficiency with basic computer skills and EMR systems.
• Experience with motivational interviewing, trauma-informed care, and care coordination.
• Strong interpersonal communication and ability to work independently.
• Multilingual skills are a plus.
• Prior home care experience is beneficial.

Responsibilities

• Deliver chronic care management to high-complexity patients in home settings.
• Guide enrollment processes and schedule virtual appointments.
• Ensure adherence to care plans and coordinate with providers.
• Build relationships and educate patients to promote health and reduce hospitalizations.
• Support documentation and data management within EMR.

Skills

Care coordination

Interpersonal communication

Motivational interviewing

Trauma-informed care

Time management

Independent work

Multilingual

Home care experience

EMR proficiency

Patient education

Education

High school diploma or GED

Tools

EMR

Job description

Upward Health specializes in in-home, multidisciplinary care, delivering 24/7 whole-person services across physical, behavioral, and social health needs. The Care Specialist leads chronic care management for high‑complexity patients, primarily in home settings with some virtual visits, guiding enrollment and coordinating with providers.

The role emphasizes building relationships, patient education, adherence to care plans, and reducing hospitalizations while improving outcomes through proactive