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

Job Description:

CARE SPECIALIST

• ECMAre 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 “whyYour 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 chance forself-improvement and growth. Self-awareness is your ally, and youthrive as an independent problem solver. Your passion for people isthe driving force behind your commitment to delivering high-qualitycare.

If you possess these qualities and are ready to embrace a rolethat demands dedication, adaptability, and a deep desire to make apositive impact, we encourage you to explore the possibilities ofbecoming a Care Specialist within our organization. Join us in ourmission to provide exceptional care and support to those who needit most.

Who is Upward HealthUpward Health is an in-home,multidisciplinary medical group providing 24/7 whole-person care.

Our clinical team treats physical, behavioral, and social healthneeds when and where a patient needs help. Everyone on our teamfrom our providers, nurses, and Care Specialists to our HR,Technology, and Business Services staff are driven by a desire toimprove the lives of our patients. We are able to treat a widerange of needs

• everything from addressing poorly controlled bloodsugar to combatting anxiety to accessing medically tailored meals
• because we know that health requires care for the whole person.

It’s no wonder 98% of patients report being fully satisfied withUpward Health!

What you will do.

The Care Specialist works inpatient’s homes and community 90% of the time and virtually theother 10% to deliver chronic care management to high complexitypatients. During initial outreach the Care Specialist informspatients about our services and helps them get enrolled.

• Reachingout via phone is our top strategy for outreach and it’s importantthat the Care Specialist is comfortable and confident communicatingby phone.
• Field-based approaches are utilized as well, and theCare Specialist should be prepared to use whatever strategy is mosteffective.
• Once the patient is enrolled, the Care Specialist willcoordinate care from the patient’s home or the community to supportour integrated care delivery model, focused on the following goals:

Promote timely access to appropriate care; increase utilization ofpreventative care; reduce emergency room utilization and hospitalreadmissions; create and promote adherence to a care plan developedin coordination with the patient, primary care provider, andfamily/caregiver(s); increase patient’s ability for self-managementand shared decision-making; provide medication reconciliation;connect patients to relevant community resources, with the goal ofenhancing patient health and well-being, increasing patientsatisfaction, and reducing health care costs

KEYRESPONSIBILITIES

Conduct direct outreach to patients via phone, in-person,mailings, and other strategies including cold calling andunscheduled door knocks.

• Enroll patients into Upward Health’s program and collect keydata about patients during the enrollment process throughcontinuous and on-going phone and in-person interactions.
• Meets patients in their home or in the community to conduct aneeds assessment, including helping patients to set healthgoals. Coordinate care between patients and interdisciplinary careteams as needed.
• Support your patients in meeting their healthcare goals as itrelates to Quality measures. Work within an interdisciplinary team to support the team’seffort in meeting market and/or organizational goals.
• Analyze patient data to determine patient needs or treatmentgoals.

Assess physical conditions of patients to aid in diagnosis,treatment; and/or need for additional referrals in support ofhealth and social needs. Explain technical medical information to educate thepatients. Cultivate and support the primary care providers with timelycommunication, inquiry follow-up, and integration of informationinto the care plan regarding transitions-in-care and referral. Builds rapport with Upward Health patients utilizingmotivational interviewing techniques. Conduct one-on-one extended in-person patientappointments. Makes follow-up calls and home visits to patients per UpwardHealth policy. Documents each patient encounter with accuracy andprecision. Prepares reports and documents as needed or requested. Attends regular daily huddle, team meetings and participates inclinical rounds. Other duties as needed.•

KNOWLEDGE, SKILLS & ABILITIES

Strong critical thinking skills for assessing patient needs andtreatment goals. Self-starter with the ability to work independently in anunstructured environment. Interpersonal savvy, demonstrated by the ability to interactwith and influence people to establish trust and build strongrelationships. Familiar with concepts like Motivational interviewing, traumainformed care and care coordination. Ability to complete unscheduled home visits, completedcold-calls and outreach. Strong organization skills and ability to manage and maintain apersonal schedule. Proficient in time management and the ability to prioritizetasks effectively.

• Ability to work independently within a field-based environmentand as part of a team. Excellent communication and motivational interviewing skills toengage with difficult patients and the ability to explain technicalmedical information.
• Proficient in the accurate and timely documentation of patientinformation in multiple electronic medical record (EMR) systems toensure seamless continuity of care and data integrity

•

QUALIFICATIONS

At least 2 years of relevant work experience as a CommunityHealth Worker, Peer Support Specialist, Medical Assistant, orsimilar role High school graduate or GED required. A valid driver’s license and auto liability insurance. Reliable transportation and the ability to travel within yourassigned territory or other as needed to support the patient needsplan and training requirements. Experience in Chronic Care Management model OR experience withchronically ill/elderly patients. Long-time resident of the community with good knowledge of theresources of this community. Ability to complete Upward Health’s initial training programand ongoing educational requirements as assigned, both virtuallyand in-person.

• Technologically savvy with basic computer skills, includingability to type. Multi-lingual capabilities preferred, but not required. Prior Home Care experience a plusUpward Health is proud to bean equal opportunity/affirmative action employer. We are committedto attracting, retaining, and maximizing the performance of adiverse and inclusive workforce.
• This job description is a generaloutline of duties performed and is not to be misconstrued asencompassing all duties performed within the position.
• Compensation details: 24-27 HourlyWagePI57edf31cf499-37820-35961867