In-Home Chronic Care Navigator

Upward Health; Stamford (CT); On-site; USD 52,000 - 72,000; Full time

Job summary

Upward Health is an in-home, multidisciplinary medical group delivering 24/7 whole-person care. The Care Specialist role focuses on chronic care management for high-complexity patients, mostly in patients' homes with occasional virtual contact.

You will enroll patients, coordinate care, and educate them to improve outcomes and reduce hospitalizations. The position emphasizes outreach, independence in unstructured settings, and strong communication skills to engage patients, families, and

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 and communities (90%) with some virtual care (10%).
• Outreach to patients, guide enrollment, and coordinate virtual appointments with providers.
• Educate patients and coordinate care to promote health and prevent unnecessary hospitalizations.
• Build relationships and promote adherence to care plans to improve outcomes.

Skills

Interpersonal communication

Motivational interviewing

Care coordination

Time management

Independent work

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. The Care Specialist role focuses on chronic care management for high-complexity patients, mostly in patients' homes with occasional virtual contact.

You will enroll patients, coordinate care, and educate them to improve outcomes and reduce hospitalizations. The position emphasizes outreach, independence in unstructured settings, and strong communication skills to engage patients, families, and