Care Specialist Community Health Worker

Company: Upward Health
Location: Bronx
Posted on: November 19, 2023

Job Description:

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 doctors, 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!WHY IS THIS ROLE CRITICAL?We are currently recruiting for an experienced, personable Community Health Worker to work in patient's homes and virtually to deliver chronic care management to high complexity patients. This position assists our Providers in the coordination of care with patients not limited to but including calls to the patients, assisting with referrals, medication adjustments, and general assistance that may be too time consuming to be completed at the time of the office visit. The position with also 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 careIncrease utilization of preventative careReduce emergency room utilization and hospital readmissionsCreate 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-makingProvide medication reconciliationConnect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costsThe ideal candidate must be flexible and willing to work in an early-stage company on an innovative pilot program where the scope of services and protocols will evolve. This will be a dynamic environment that requires flexibility, dedication, and commitment to improve care for underserved populations.KEY RESPONSIBILITIES: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 communicationsServe as the contact point, advocate, and information resource for patients and their care team.Create ongoing process for patients and family/caregiver(s) to determine and request the level of care coordinates support they desire at any given point in timeFacilitate patient access to appropriate medical and specialty providersFacilitate appointments between patients and care team as neededInterview patients to gather medical information.Record vital statistics and other health information in electronic medical record (EMR)Monitor patients to detect health problems.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 patients.Collect medical information from patients, family members, or other medical professionals.Administer basic health care or medical treatments as directed by Upward Health care providersOperate medical equipment (glucometer, electronic devices for V.S. monitoring)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 referralBuilds rapport with Upward Health patients utilizing motivational interviewing techniquesStrong organizational skills to assist patients coordinating services across providersMeets patients in their home or in the community to conduct a needs assessment, including helping patients to set health goalsMakes follow-up calls and home visits to patients per Upward Health policyCoordinates with Clinical Care teamDocuments each patient encounter in detail per Upward Health PoliciesPrepares reports and documents as needed or requestedAttends regular team meetings and participate in clinical roundsPerforms other duties as assignedKNOWLEDGE, SKILLS & ABILITIES:Interpersonal savvy, with the demonstrated by the ability to interact with and influence people to establish trust and build strong relationshipsAbility to do home visits and outreachExperience with usage of EMR/EHRsExperience working in a high-volume physician practice, hospital setting, or possibly a home care role.Comfortable with computer data entryStrong organization skills and ability to manage and maintain a personal scheduleAbility to establish priorities and meet deadlinesAbility to work independently within a virtual operating environment and as part of a teamExcellent oral and written communication skillsAbility to exercise judgment in the application of professional servicesQUALIFICATIONS:High school graduate or GED requiredExperience in Chronic Care Management model OR experience with chronically ill/elderly patientsLong-time resident of the community with good knowledge of the resources of this communityA valid driver's license and auto liability insuranceExperience working as a community health workers or peer support specialist is a plusAble to maintain clear professional boundaries with members and coworkersAbility to complete Upward Health's initial training program and ongoing educational requirements as assignedCommitment to represent the company with professionalismCultural competency - able to work with diverse groups of community membersBasic computer skills, including ability to typeMulti-lingual capabilities preferred, but not requiredStrong communication and problem-solving skillsTechnologically savvyPrior Home Care experience a plusPrior experience as a Community Health Worker, Peer Support Specialist, or similar role a plusUpward 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: 23-25 Hourly WagePI56e5e154472f-25660-33142771

Keywords: Upward Health, Mount Vernon , Care Specialist Community Health Worker, Healthcare , Bronx, New York