In-Home Chronic Care Specialist

Upward Health, Inc.; Providence (RI); On-site; USD 45,000 - 60,000; Full time

Job summary

Upward Health is seeking a Care Specialist to deliver chronic care management primarily in patients' homes, with supplemental virtual care. The role focuses on outreach, enrollment guidance, and coordinating care plans to improve outcomes and reduce hospitalizations.

A valid driver’s license and experience with chronic care are preferred. Candidates should be proficient with EMR systems, possess strong communication skills, and be able to work independently in an unstructured environment while

Qualifications

• 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 (90%) and some virtual care (10%).
• Engage in direct outreach to patients, guiding enrollment, coordinating virtual appointments, and ensuring adherence to care plans.
• Build relationships, coordinate care, and educate patients to promote health and reduce hospitalizations.

Skills

Community Health Worker

Chronic Care Management

Motivational Interviewing

Trauma-Informed Care

Care Coordination

EMR Systems

Interpersonal Skills

Time Management

Independent Work

Multilingual Ability

Education

High school diploma or GED

Tools

EMR Systems

Job description

Upward Health is seeking a Care Specialist to deliver chronic care management primarily in patients' homes, with supplemental virtual care. The role focuses on outreach, enrollment guidance, and coordinating care plans to improve outcomes and reduce hospitalizations.

A valid driver’s license and experience with chronic care are preferred. Candidates should be proficient with EMR systems, possess strong communication skills, and be able to work independently in an unstructured environment while