In-Home Chronic Care Navigator

Upward Health, Inc.; Bridgeport (IL); Hybrid; USD 36,000 - 48,000; Full time

Job summary

Upward Health, Inc. is seeking a Care Specialist to deliver chronic care management for high-complexity patients, primarily in patients' homes with some virtual care.

You will outreach to patients, guide enrollment, and coordinate virtual appointments with providers to ensure adherence to care plans. This role emphasizes building relationships, coordinating care, and educating patients to prevent hospitalizations and improve outcomes.

Qualifications

• Minimum 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

• The Care Specialist delivers chronic care management to high-complexity patients, primarily in patients' homes and communities (90%), with some virtual care (10%).
• Engages in direct outreach to patients, guides enrollment, and facilitates virtual appointments with providers.
• Ensures patients adhere to care plans and coordinates care to promote health and prevent hospitalizations.

Skills

Care coordination

Motivational interviewing

Interpersonal communication

Time management

Home care experience

Driver's license

Multi-lingual skills

Chronic care management

Trauma-informed care

EMR familiarity

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, primarily in patients' homes with some virtual care.

You will outreach to patients, guide enrollment, and coordinate virtual appointments with providers to ensure adherence to care plans. This role emphasizes building relationships, coordinating care, and educating patients to prevent hospitalizations and improve outcomes.