In-Home Chronic Care Specialist & Advocate

Upward Health, Inc.; Warwick (RI); On-site; USD 42,000 - 64,000; Full time

Job summary

Upward Health, Inc. is a home-based, multidisciplinary medical group delivering chronic care management to high-complexity patients. The Care Specialist primarily works in patients' homes and communities (90%) and engages in virtual care (10%).

You will guide enrollment, coordinate care, and ensure adherence to plans to improve outcomes. This role requires a valid driver’s license, the ability to travel within the territory, and strong communication skills to engage patients and teams

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.
• Engage in virtual care 10% of the time.
• Guide patients through enrollment and facilitate appointments with providers.
• Coordinate care and ensure adherence to care plans to improve outcomes.
• Build relationships and educate patients to promote health and prevent hospitalizations.

Skills

2+ years experience

Driver's license

EMR proficiency

Motivational interviewing

Care coordination

Multilingual (nice to have)

Education

High school diploma or GED

Tools

EMR systems

Job description

Upward Health, Inc. is a home-based, multidisciplinary medical group delivering chronic care management to high-complexity patients. The Care Specialist primarily works in patients' homes and communities (90%) and engages in virtual care (10%).

You will guide enrollment, coordinate care, and ensure adherence to plans to improve outcomes. This role requires a valid driver’s license, the ability to travel within the territory, and strong communication skills to engage patients and teams