In-Home Chronic Care Coordinator

Upward Health, Inc.; Coram (NY); On-site; USD 29,000 - 34,000; 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 90% home visits and 10% virtual care, guiding enrollment and coordinating care.

You will build rapport, educate patients, and coordinate with providers to promote health outcomes and reduce hospitalizations. A valid driver’s license and EMR proficiency are required.

Qualifications

• Minimum 2 years of relevant work experience in community health or related roles.
• High school diploma or GED required.
• Valid driver's license, auto liability insurance, and reliable transportation within territory.
• Experience in chronic care management or with chronically ill/elderly patients.
• Technologically proficient with basic computer skills and EMR systems.
• Experience with motivational interviewing, trauma-informed care, and care coordination.
• Strong interpersonal communication skills for engaging patients and team members.
• Ability to prioritize tasks, manage schedules, and work independently in unstructured environments.
• Multilingual 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%) with some virtual care (10%).
• Outreach to patients and guide them through enrollment in care programs.
• Facilitate virtual appointments with providers and ensure adherence to care plans.
• Build relationships, coordinate care, and educate patients to improve outcomes.
• Collaborate with interdisciplinary teams to meet patient and organizational goals.

Skills

Experience 2+ yrs in CHW/PS/MA

High school diploma or GED

Driver's license & reliable transport

Chronic care management experience

EMR computer skills

Motivational interviewing

Interpersonal communication

Time management

Multilingual a plus

Home care experience beneficial

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 90% home visits and 10% virtual care, guiding enrollment and coordinating care.

You will build rapport, educate patients, and coordinate with providers to promote health outcomes and reduce hospitalizations. A valid driver’s license and EMR proficiency are required.