In-Home Chronic Care Navigator

Upward Health; New York (NY); On-site; USD 42,000 - 62,000; Full time

Job summary

Upward Health is an in-home, multidisciplinary medical group delivering 24/7 whole-person care in New York and surrounding areas. The Care Specialist focuses on delivering chronic care management to high‑complexity patients, primarily in patients' homes (90%) with some virtual care (10%).

The role involves direct outreach, guiding enrollment, coordinating with providers, and ensuring adherence to care plans, with a focus on preventing hospitalizations and improving outcomes.

Qualifications

• Minimum 2 years of relevant work experience in community health, care coordination, or similar 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 working with chronically ill/elderly patients.
• Technologically proficient with basic computer skills and EMR systems.
• Experience with motivational interviewing and trauma-informed care.
• Strong interpersonal communication and ability to work independently.
• Multilingual skills are a plus but not required.

Responsibilities

• Conduct outreach to patients and guide enrollment processes.
• Deliver chronic care management while primarily in patients’ homes (90%) with some virtual care (10%).
• Facilitate virtual appointments with providers and coordinate care plans.
• Promote adherence to care plans and improve patient outcomes.

Skills

Community Health Worker

Care Coordination

Motivational Interviewing

Interpersonal Communication

Independent Work

EMR Systems

Education

High school diploma or GED

Tools

EMR Systems

Job description

Upward Health is an in-home, multidisciplinary medical group delivering 24/7 whole-person care in New York and surrounding areas. The Care Specialist focuses on delivering chronic care management to high‑complexity patients, primarily in patients' homes (90%) with some virtual care (10%).

The role involves direct outreach, guiding enrollment, coordinating with providers, and ensuring adherence to care plans, with a focus on preventing hospitalizations and improving outcomes.