Care Specialist - Enhanced Care Management
Company: Upward Health
Location: Brentwood
Posted on: June 26, 2025
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Job Description:
CARE SPECIALIST - ECM Are you a dedicated individual with a
passion for providing quality care and making a positive impact in
the lives of others? If you possess a unique blend of skills and
attributes, including critical thinking, resilience, and the
ability to thrive in unstructured environments, we invite you to
consider joining our team as a Care Specialist. As a Care
Specialist, you will play a crucial role in our organization,
working in a dynamic and ever-changing field. Your responsibilities
will extend beyond the ordinary, and we are looking for someone who
possesses the tenacity, resilience, and perseverance to excel in
challenging situations. Your role will require you to be a
self-starter, someone who not only understands the art of
prioritization but is also keen to understand the "why" behind what
we do. You'll engage with individuals from diverse backgrounds and
often with complex needs, so the ability to work with difficult
people 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 community
and diversity will be vital in ensuring that you provide culturally
sensitive and inclusive care. Organizational skills,
responsiveness, and flexibility are key as you navigate the
ever-evolving landscape of healthcare. Your self-motivation and
ability to pivot, serving as a change agent when necessary, will be
highly valued. You have an outcome-oriented approach and are
willing to learn, adapting to new challenges and opportunities with
enthusiasm. Criticism doesn't deter you; you take it as a chance
for self-improvement and growth. Self-awareness is your ally, and
you thrive as an independent problem solver. Your passion for
people is the driving force behind your commitment to delivering
high-quality care. If you possess these qualities and are ready to
embrace a role that demands dedication, adaptability, and a deep
desire to make a positive impact, we encourage you to explore the
possibilities of becoming a Care Specialist within our
organization. Join us in our mission to provide exceptional care
and support to those who need it most. Who is Upward Health Upward
Health is an in-home, multidisciplinary medical group providing
24/7 whole-person care. Our clinical team treats physical,
behavioral, and social health needs when and where a patient needs
help. Everyone on our team from our providers, nurses, and Care
Specialists to our HR, Technology, and Business Services staff are
driven by a desire to improve the lives of our patients. We are
able to treat a wide range of needs – everything from addressing
poorly controlled blood sugar 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 with Upward Health! What you will do. The
Care Specialist works in patient’s homes and community 90% of the
time and virtually the other 10% to deliver chronic care management
to high complexity patients. During initial outreach the Care
Specialist informs patients about our services and helps them get
enrolled. Reaching out via phone is our top strategy for outreach
and it’s important that the Care Specialist is comfortable and
confident communicating by phone. Field-based approaches are
utilized as well, and the Care Specialist should be prepared to use
whatever strategy is most effective. Once the patient is enrolled,
the Care Specialist will coordinate care from the patient’s home or
the community to support our integrated care delivery model,
focused on the following goals: Promote timely access to
appropriate care; increase utilization of preventative care; reduce
emergency room utilization and hospital readmissions; create and
promote adherence to a care plan developed in coordination with the
patient, primary care provider, and family/caregiver(s); increase
patient’s ability for self-management and shared decision-making;
provide medication reconciliation; connect patients to relevant
community resources, with the goal of enhancing patient health and
well-being, increasing patient satisfaction, and reducing health
care costs KEY RESPONSIBILITIES: Conduct direct outreach to
patients via phone, in-person, mailings, and other strategies
including cold calling and unscheduled door knocks. Enroll patients
into Upward Health’s program and collect key data about patients
during the enrollment process through continuous and on-going phone
and in-person interactions. Meets patients in their home or in the
community to conduct a needs assessment, including helping patients
to set health goals. Coordinate care between patients and
interdisciplinary care teams as needed. Support your patients in
meeting their healthcare goals as it relates to Quality measures.
Work within an interdisciplinary team to support the team’s effort
in meeting market and/or organizational goals. Analyze patient data
to determine patient needs or treatment goals. Assess physical
conditions of patients to aid in diagnosis, treatment; and/or need
for additional referrals in support of health and social needs.
Explain technical medical information to educate the patients.
Cultivate and support the primary care providers with timely
communication, inquiry follow-up, and integration of information
into the care plan regarding transitions-in-care and referral.
Builds rapport with Upward Health patients utilizing motivational
interviewing techniques. Conduct one-on-one extended in-person
patient appointments. Makes follow-up calls and home visits to
patients per Upward Health policy. Documents each patient encounter
with accuracy and precision. Prepares reports and documents as
needed or requested. Attends regular daily huddle, team meetings
and participates in clinical rounds. Other duties as needed.
KNOWLEDGE, SKILLS & ABILITIES: Strong critical thinking skills for
assessing patient needs and treatment goals. Self-starter with the
ability to work independently in an unstructured environment.
Interpersonal savvy, demonstrated by the ability to interact with
and influence people to establish trust and build strong
relationships. Familiar with concepts like Motivational
interviewing, trauma informed care and care coordination. Ability
to complete unscheduled home visits, completed cold-calls and
outreach. Strong organization skills and ability to manage and
maintain a personal schedule. Proficient in time management and the
ability to prioritize tasks effectively. Ability to work
independently within a field-based environment and as part of a
team. Excellent communication and motivational interviewing skills
to engage with difficult patients and the ability to explain
technical medical information. Proficient in the accurate and
timely documentation of patient information in multiple electronic
medical record (EMR) systems to ensure seamless continuity of care
and data integrity. QUALIFICATIONS: At least 2 years of relevant
work experience as a Community Health Worker, Peer Support
Specialist, Medical Assistant, or similar role High school graduate
or GED required. A valid driver’s license and auto liability
insurance. Reliable transportation and the ability to travel within
your assigned territory or other as needed to support the patient
needs plan and training requirements. Experience in Chronic Care
Management model OR experience with chronically ill/elderly
patients. Long-time resident of the community with good knowledge
of the resources of this community. Ability to complete Upward
Health’s initial training program and ongoing educational
requirements as assigned, both virtually and in-person.
Technologically savvy with basic computer skills, including ability
to type. Multi-lingual capabilities preferred, but not required.
Prior Home Care experience a plus Upward Health is proud to be an
equal opportunity/affirmative action employer. We are committed to
attracting, retaining, and maximizing the performance of a diverse
and inclusive workforce. This job description is a general outline
of duties performed and is not to be misconstrued as encompassing
all duties performed within the position. Compensation details:
24-27 Hourly Wage PId4cbe763edd3-35216-35961878
Keywords: Upward Health, Rancho Cordova , Care Specialist - Enhanced Care Management, Healthcare , Brentwood, California
