Care Specialist – Enhanced Care Management Position Available In Merrimack, New Hampshire

Job Description:

CARE SPECIALIST

• ECM Are you a dedicated individual with apassion for providing quality care and making a positive impact inthe lives of others?

If you possess a unique blend of skills andattributes, including critical thinking, resilience, and theability to thrive in unstructured environments, we invite you toconsider joining our team as a Care Specialist. As a CareSpecialist, you will play a crucial role in our organization,working in a dynamic and ever-changing field. Your responsibilitieswill extend beyond the ordinary, and we are looking for someone whopossesses the tenacity, resilience, and perseverance to excel inchallenging situations. Your role will require you to be aself-starter, someone who not only understands the art ofprioritization but is also keen to understand the “why” behind whatwe do. You’ll engage with individuals from diverse backgrounds andoften with complex needs, so the ability to work with difficultpeople and always be willing to help is a must. You don’t just say”no”; you ask “how” and seek the “why Your awareness of communityand diversity will be vital in ensuring that you provide culturallysensitive and inclusive care. Organizational skills,responsiveness, and flexibility are key as you navigate theever-evolving landscape of healthcare. Your self-motivation andability to pivot, serving as a change agent when necessary, will behighly valued. You have an outcome-oriented approach and arewilling to learn, adapting to new challenges and opportunities withenthusiasm. Criticism doesn’t deter you; you take it as a chancefor self-improvement and growth. Self-awareness is your ally, andyou thrive as an independent problem solver. Your passion forpeople is the driving force behind your commitment to deliveringhigh-quality care. If you possess these qualities and are ready toembrace a role that demands dedication, adaptability, and a deepdesire to make a positive impact, we encourage you to explore thepossibilities of becoming a Care Specialist within ourorganization. Join us in our mission to provide exceptional careand support to those who need it most. Who is Upward Health UpwardHealth is an in-home, multidisciplinary medical group providing24/7 whole-person care. Our clinical team treats physical,behavioral, and social health needs when and where a patient needshelp. Everyone on our team from our providers, nurses, and CareSpecialists to our HR, Technology, and Business Services staff aredriven by a desire to improve the lives of our patients. We areable to treat a wide range of needs

• everything from addressingpoorly controlled blood sugar to combatting anxiety to accessingmedically tailored meals
• because we know that health requirescare for the whole person.

It’s no wonder 98% of patients reportbeing fully satisfied with Upward Health! What you will do. TheCare Specialist works in patient’s homes and community 90% of thetime and virtually the other 10% to deliver chronic care managementto high complexity patients. During initial outreach the CareSpecialist informs patients about our services and helps them getenrolled. Reaching out via phone is our top strategy for outreachand it’s important that the Care Specialist is comfortable andconfident communicating by phone. Field-based approaches areutilized as well, and the Care Specialist should be prepared to usewhatever strategy is most effective. Once the patient is enrolled,the Care Specialist will coordinate care from the patient’s home orthe community to support our integrated care delivery model,focused on the following goals: Promote timely access toappropriate care; increase utilization of preventative care; reduceemergency room utilization and hospital readmissions; create andpromote adherence to a care plan developed in coordination with thepatient, primary care provider, and family/caregiver(s); increasepatient’s ability for self-management and shared decision-making;provide medication reconciliation; connect patients to relevantcommunity resources, with the goal of enhancing patient health andwell-being, increasing patient satisfaction, and reducing healthcare costs

KEY RESPONSIBILITIES

• Conduct direct outreach topatients via phone, in-person, mailings, and other strategiesincluding cold calling and unscheduled door knocks.
• Enrollpatients into Upward Health’s program and collect key data aboutpatients during the enrollment process through continuous andon-going phone and in-person interactions.
• Meets patients intheir home or in the community to conduct a needs assessment,including helping patients to set health goals.
• Coordinate carebetween patients and interdisciplinary care teams as needed.
• Support your patients in meeting their healthcare goals as itrelates to Quality measures.
• Work within an interdisciplinaryteam to support the team’s effort in meeting market and/ororganizational goals.
• Analyze patient data to determine patientneeds or treatment goals.
• Assess physical conditions of patientsto aid in diagnosis, treatment; and/or need for additionalreferrals in support of health and social needs.
• Explaintechnical medical information to educate the patients.
• Cultivateand support the primary care providers with timely communication,inquiry follow-up, and integration of information into the careplan regarding transitions-in-care and referral.
• Builds rapportwith Upward Health patients utilizing motivational interviewingtechniques.
• Conduct one-on-one extended in-person patientappointments.
• Makes follow-up calls and home visits to patientsper Upward Health policy.
• Documents each patient encounter withaccuracy and precision.
• Prepares reports and documents as neededor requested.
• Attends regular daily huddle, team meetings andparticipates in clinical rounds.
• Other duties as needed.

KNOWLEDGE, SKILLS & ABILITIES

• Strong critical thinking skillsfor assessing patient needs and treatment goals.
• Self-starterwith the ability to work independently in an unstructuredenvironment.
• Interpersonal savvy, demonstrated by the ability tointeract with and influence people to establish trust and buildstrong relationships.
• Familiar with concepts like Motivationalinterviewing, trauma informed care and care coordination.
• Abilityto complete unscheduled home visits, completed cold-calls andoutreach.
• Strong organization skills and ability to manage andmaintain a personal schedule.
• Proficient in time management andthe ability to prioritize tasks effectively.
• Ability to workindependently within a field-based environment and as part of ateam.
• Excellent communication and motivational interviewingskills to engage with difficult patients and the ability to explaintechnical medical information.
• Proficient in the accurate andtimely documentation of patient information in multiple electronicmedical record (EMR) systems to ensure seamless continuity of careand data integrity.

QUALIFICATIONS

• At least 2 years of relevantwork experience as a Community Health Worker, Peer SupportSpecialist, Medical Assistant, or similar role
• High schoolgraduate or GED required.
• A valid driver’s license and autoliability insurance.
• Reliable transportation and the ability totravel within your assigned territory or other as needed to supportthe patient needs plan and training requirements.
• Experience inChronic Care Management model OR experience with chronicallyill/elderly patients.
• Long-time resident of the community withgood knowledge of the resources of this community.
• Ability tocomplete Upward Health’s initial training program and ongoingeducational requirements as assigned, both virtually and in-person
• Technologically savvy with basic computer skills, includingability to type.
• Multi-lingual capabilities preferred, but notrequired.
• Prior Home Care experience a plus Upward Health isproud to be an equal opportunity/affirmative action employer.

Weare committed to attracting, retaining, and maximizing theperformance of a diverse and inclusive workforce. This jobdescription is a general outline of duties performed and is not tobe misconstrued as encompassing all duties performed within theposition.

Compensation details:

24-27 Hourly WagePI73a6d07d654e-37156-35961867