In-Home Chronic Care Navigator

Upward Health; Waterbury (CT); On-site; USD 29,000 - 34,000; Full time

Job summary

Upward Health is seeking a Care Specialist to deliver chronic care management in patients’ homes and via virtual visits. The role centers on outreach, enrollment guidance, and coordinating care with providers to support patients in managing their health and adherence to care plans.

You will engage patients, educate them on care plans, and coordinate services to improve outcomes while working within a multidisciplinary team in a home-based setting.

Qualifications

• Minimum of 2 years of relevant work experience (e.g., Community Health Worker, Peer Support Specialist, Medical Assistant).
• High school diploma or GED required.
• 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.
• Tech/proficient with basic computer skills (typing, EMR systems).
• Experience with motivational interviewing, trauma-informed care, and care coordination.
• Strong interpersonal communication and 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.

Responsibilities

• Deliver chronic care management to high-complexity patients, primarily in patients' homes (90%) and some virtual care (10%).
• Guide patients through enrollment, coordinate care, and facilitate virtual appointments with providers.
• Build relationships, educate patients, and promote health to prevent hospitalizations and improve outcomes.

Skills

Motivational interviewing

Care coordination

EMR proficiency

Communication skills

Time management

Driver's license

Independent work

Education

High school diploma or GED

Tools

EMR software

Job description

Upward Health is seeking a Care Specialist to deliver chronic care management in patients’ homes and via virtual visits. The role centers on outreach, enrollment guidance, and coordinating care with providers to support patients in managing their health and adherence to care plans.

You will engage patients, educate them on care plans, and coordinate services to improve outcomes while working within a multidisciplinary team in a home-based setting.