In-Home Chronic Care Navigator

Upward Health; Centereach (NY); On-site; USD 29,000 - 34,000; Full time

Job summary

Upward Health is seeking a Care Specialist to deliver chronic care management to high‑complexity patients, mostly in patients’ homes with occasional virtual visits. Your role includes enrollment guidance, coordinating with providers, and ensuring adherence to care plans.

You will build rapport, coordinate care, and educate patients to promote health, prevent unnecessary hospitalizations, and improve outcomes. A valid driver’s license and reliable transportation are required.

Qualifications

• Minimum of 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 for travel 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 and care coordination.
• Strong interpersonal communication skills and ability to work independently.

Responsibilities

• Deliver chronic care management to high‑complexity patients, primarily in patients' homes (90%) and some virtual care (10%).
• Guide patients through enrollment, facilitate virtual appointments, and ensure adherence to care plans.
• Build relationships and coordinate care to improve patient outcomes and reduce hospitalizations.

Skills

Community Health Worker

Care Coordination

Motivational Interviewing

Interpersonal Communication

Time Management

EMR Proficiency

Bilingual (optional)

Education

High school diploma or GED

Tools

EMR Systems

Job description

Upward Health is seeking a Care Specialist to deliver chronic care management to high‑complexity patients, mostly in patients’ homes with occasional virtual visits. Your role includes enrollment guidance, coordinating with providers, and ensuring adherence to care plans.

You will build rapport, coordinate care, and educate patients to promote health, prevent unnecessary hospitalizations, and improve outcomes. A valid driver’s license and reliable transportation are required.