Home-Based Chronic Care Specialist

The Blue Venture Fund; Casa Grande (AZ); On-site; USD 42,000 - 52,000; Full time

Job summary

Upward Health is hiring a Care Specialist to deliver chronic care management to high-complexity patients, mainly in patients' homes with some virtual care. You will guide enrollment, coordinate care, and ensure adherence to individualized care plans.

The role emphasizes building relationships, educating patients, and reducing preventable hospitalizations while working with an interdisciplinary team and using EMR systems.

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.
• 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, primarily in patients' homes (90%) and some virtual visits (10%).
• Engage in outreach to patients, guide enrollment, facilitate virtual appointments, and ensure adherence to care plans.
• Build relationships, coordinate care, and provide education to improve outcomes and prevent hospitalizations.

Skills

2+ years experience

Community Health Worker

Peer Support

Medical Assistant

EMR systems

Motivational interviewing

Trauma-informed care

Care coordination

Interpersonal communication

Time management

Education

High school diploma or GED

Tools

EMR systems

Job description

Upward Health is hiring a Care Specialist to deliver chronic care management to high-complexity patients, mainly in patients' homes with some virtual care. You will guide enrollment, coordinate care, and ensure adherence to individualized care plans.

The role emphasizes building relationships, educating patients, and reducing preventable hospitalizations while working with an interdisciplinary team and using EMR systems.