In-Home Chronic Care Specialist

upwardhealth; Phoenix (AZ); On-site; USD 50,000 - 70,000; Full time

Job summary

Upward Health in Phoenix, AZ is seeking a Care Specialist to deliver chronic care management primarily in patients' homes and communities, with some virtual care.

You will lead enrollment, coordinate care with providers, support patient education, and help prevent hospitalizations by promoting adherence to care plans.

This role requires strong communication, reliability, and the ability to work independently within an unstructured environment while traveling within the assigned territory.

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 primarily in patients' homes and communities (90% home visits, 10% virtual care).
• Direct outreach to patients, guide enrollment, facilitate virtual appointments with providers, and ensure adherence to care plans.
• Build relationships, coordinate care, and provide education to promote health and prevent hospitalizations.

Skills

Community Health Worker

Medical Assistant

Interpersonal communication

Motivational interviewing

Trauma-informed care

EMR proficiency

Multilingual skills

Time management

Independent work

Reliable transportation

Education

High school diploma or GED

Tools

EMR systems

Job description

Upward Health in Phoenix, AZ is seeking a Care Specialist to deliver chronic care management primarily in patients' homes and communities, with some virtual care.

You will lead enrollment, coordinate care with providers, support patient education, and help prevent hospitalizations by promoting adherence to care plans.

This role requires strong communication, reliability, and the ability to work independently within an unstructured environment while traveling within the assigned territory.