Care Specialist Medical Assistant

The Care Specialist works in patient’s homes and virtually to deliver chronic care management to high complexity patients. This position is the first point of contact with our company for our patients. We count on the Care Specialist to make an excellent first impression and to be able to effectively communicate our service offering to 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 facilitate virtual visits from the patient’s home to our providers remotely 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
Upward Health provides technology-enabled, integrated, and coordinated care delivery services that improve outcomes and reduce costs for patients with severe behavioral health diagnoses and co-morbid, chronic physical conditions. We are not your typical medical practice. At Upward Health, we see every day as an opportunity to make a difference in our patients' lives. We could tell you about our outcomes and patient satisfaction ratings. We could tell you about our commitment to our mission, or you could join us and experience it all for yourself.
Key Responsibilities

• Builds rapport with Upward Health patients utilizing motivational interviewing techniques
• Assess physical conditions of patients to aid in diagnosis, treatment; and/or need for additional referrals in support of health and social needs.
• Monitor patients to detect health problems.
• Collect medical information from patients, family members, or other medical professionals.
• Attends regular team meetings and participate in clinical rounds
• Analyze patient data to determine patient needs or treatment goals.
• Enroll patients into Upward Health’s program and collect key data about patients during the enrollment process
• Record vital statistics and other health information in electronic medical record (EMR)
• Explain technical medical information to patients.
• Makes follow-up calls and home visits to patients per Upward Health policy
• Documents each patient encounter in detail per Upward Health Policies
• Speak with patients about the role that Upward Health can play in helping them improve their health
• Facilitate appointments between patients and care team as needed
• Conduct one-on-one extended patient calls for initial care plans, follow-up with patients, family/caregiver(s), providers, and community resources via secure e-mail, phone calls, and other communications
• Operate medical equipment (glucometer, electronic devices for V.S. monitoring)
• Strong organizational skills to assist patients coordinating services across providers
• Facilitate patient access to appropriate medical and specialty providers
• Conduct direct outreach to patients via phone, in-person meetings, mailings, and other strategies
• Administer basic health care or medical treatments as directed by Upward Health care providers
• Coordinates with Clinical Care team
• Meets patients in their home or in the community to conduct a needs assessment, including helping patients to set health goals
• Prepares reports and documents as needed or requested
• Capture accurate and timely documentation in our company‘s software system
• 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

Knowledge, Skills & Abilities

• Active listening skills and genuine compassion for others
• Ability to establish priorities and meet deadlines
• Knowledge of community resources in the local market
• Demonstrates cultural competency and ability to work with diverse groups of community members
• Commitment to represent the company with professionalism
• Ability to do home visits and outreach
• Ability to work independently within a virtual operating environment and as part of a team
• Experience with usage of EMR/EHRs
• Enjoys collaboration within a team environment and working with people of different skills and experience
• Experience working in a high-volume physician practice, hospital setting, or possibly a home care role.
• Able to maintain clear professional boundaries with patients and coworkers
• Interpersonal savvy, demonstrated by the ability to interact with and influence people to establish trust and build strong relationships
• Strong organization skills and ability to manage and maintain a personal schedule
• Excellent oral and written communication skills
• Comfortable using computer for documentation, communication, and organizing work
• Ability to exercise judgment in the application of professional services

Minimum Requirements

• High school graduate or GED required
• Long-time resident of the community with good knowledge of the resources of this community
• Must have reliable transportation with a valid driver’s license and auto liability insurance
• Ability to complete Upward Health’s initial training program and ongoing educational requirements as assigned
• Ability to work flexible hours, including occasional night/weekend work
• At least 3 years of relevant work experience
• Experience in Chronic Care Management model OR experience with chronically ill/elderly patients

Upward Health is proud to be an equal opportunity 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. All individuals selected for a position will undergo a background check appropriate for the position's responsibilities.

• We require all our employees to be vaccinated and to show proof of vaccination upon hire**

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