In-Home Chronic Care Navigator

upwardhealth; Warwick (RI); On-site; USD 42,000 - 56,000; Full time

Job summary

Upward Health is a home-based, multidisciplinary medical group delivering 24/7 whole-person care across physical, behavioral, and social health needs. The Care Specialist engages patients in their homes and communities, coordinating care and education to improve outcomes.

The role focuses on enrollment, care plan adherence, and virtual visits with providers, requiring strong communication, organization, and independent work in a fast-paced, patient-centered environment.

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 in patients'' homes and communities (90% travel).
• Engage in virtual care (10% of time) and guide patients through enrollment processes.
• Facilitate virtual appointments with providers and ensure adherence to care plans.
• Build relationships, coordinate care, and educate patients to promote health and prevent hospitalizations.

Skills

Chronic care management

Patient outreach

Home-based care

Motivational interviewing

Interpersonal communication

Independent work

Multilingual (nice to have)

Education

High school diploma or GED

Tools

EMR systems

Job description

Upward Health is a home-based, multidisciplinary medical group delivering 24/7 whole-person care across physical, behavioral, and social health needs. The Care Specialist engages patients in their homes and communities, coordinating care and education to improve outcomes.

The role focuses on enrollment, care plan adherence, and virtual visits with providers, requiring strong communication, organization, and independent work in a fast-paced, patient-centered environment.