Care Specialist CHW/PSS

Company: Upward Health of Rhode Island PC
Location: Lafayette
Posted on: March 16, 2023

Job Description:

Description:Care SpecialistUpward Health is a home-based medical group specializing in primary medical and behavioral care for individuals with complex needs. We serve patients throughout their communities, and we diagnose, treat, and prescribe anywhere our patients call home. We reduce barriers to care such as long delays due to scheduling. We see patients when they need us, for as much time as they need, bringing care to them. Beyond medical supports, we also assist our patients with challenges that may affect their health, such as food insecurity, social isolation, housing needs, transportation and more. It's no wonder 98% of patients report being fully satisfied with Upward Health!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.The Care Team is a multidisciplinary team of licensed and unlicensed staff who provide direct support and care to Upward Health's patients. The Care Team is comprised of a diverse team that may include registered nurses, licensed social workers, pharmacists, therapists and paramedics, care navigators and care specialists. This team works within the community and in the patients' homes or meet in agreed upon locations in the community.Why Is This Role Critical?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 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 costs ** This is a Hybrid role. When not doing amazing work with our patients, you will be expected to work from home in a space that is private, professional, and free from distraction. **Requirements:KEY RESPONSIBILITIES:OutreachConduct direct outreach to patients via phone, in-person meetings, mailings, and other strategiesSpeak with patients about the role that Upward Health can play in helping them improve their healthEnroll patients into Upward Health's program and collect key data about patients during the enrollment processCapture accurate and timely documentation in our company's software systemCare DeliveryMeets patients in their home or in the community to conduct a needs assessment, including helping patients to set health goalsFacilitate appointments between patients and care team as neededRecord 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 techniquesConduct 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 communicationsFacilitate patient access to appropriate medical and specialty providersStrong organizational skills to assist patients coordinating services across providersMakes 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, 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.Strong 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 servicesActive listening skills and genuine compassion for othersEnjoys collaboration within a team environment and working with people of different skills and experienceKnowledge of community resources in the local marketAble to maintain clear professional boundaries with patients and coworkersCommitment to represent the company with professionalismDemonstrates cultural competency and ability to work with diverse groups of community membersComfortable using computer for documentation, communication, and organizing workMINIMUM REQUIREMENTS:At least 3 years of relevant work experienceHigh 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 communityMust have reliable transportation with a valid driver's license and auto liability insuranceAbility to complete Upward Health's initial training program and ongoing educational requirements as assignedAbility to work flexible hours, including occasional night/weekend workPREFERRED QUALIFICATIONS:Multi-lingual capabilities preferred, but not requiredPrior experience as a Community Health Worker, Peer Support Specialist, Medical Assistant or similar role a plusUpward 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**PM22PI208031264

Keywords: Upward Health of Rhode Island PC, Lafayette , Care Specialist CHW/PSS, Other , Lafayette, Louisiana