Medical Assistant (Chronic Care Management)

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. Our services are delivered through a comprehensive care model provided by our clinical team. The Care Team is a multidisciplinary team of licensed and unlicensed staff who provide direct support and care to Upward Health's patients.

We are currently recruiting for an experienced, personable Certified Medical Assistant 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 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

The 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 communications
• Serve as the contact point, advocate, and information resource for patients and their care team.
• Work with patients to plan and monitor health and social needs
• Develop a care plan with the patient, family/caregiver(s) and provider
• Monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner and facilitate changes as needed
• 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 time
• Facilitate patient access to appropriate medical and specialty providers
• Facilitate appointments between patients and care team as needed
• 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
• Strong organizational skills to assist patients coordinating services across providers
• Meets patients in their home or in the community to conduct a needs assessment, including helping patients to set health goals
• Makes follow-up calls and home visits to patients per Upward Health policy
• Motivates patients to meet their health goals
• Coordinates with Clinical Care team
• Documents each patient encounter in detail per Upward Health Policies
• Prepares reports and documents as needed or requested
• Attends regular team meetings and participate in clinical rounds
• Performs other duties as assigned

KNOWLEDGE, SKILLS & ABILITIES:

• Interpersonal savvy, with the demonstrated by the ability to interact with and influence people to establish trust and build strong relationships
• Ability to do home visits and outreach
• Comfortable with computer data entry
• Strong organization skills and ability to manage and maintain a personal schedule
• Ability to establish priorities and meet deadlines
• Ability to work independently within a virtual operating environment and as part of a team
• Excellent oral and written communication skills
• Ability to exercise judgment in the application of professional services

MINIMUM REQUIREMENTS:

• Medical Assistant (MA) within state of practice
• High school graduate or GED required
• Experience in Chronic Care Management model
• Long-time resident of the community with good knowledge of the resources of this community
• A valid driver's license and auto liability insurance
• Experience working as a community health workers or peer support specialist is a plus
• Able to maintain clear professional boundaries with members and coworkers
• Ability to complete Upward Health's initial training program and ongoing educational requirements as assigned
• Commitment to represent the company with professionalism
• Cultural competency – able to work with diverse groups of community members
• Basic computer skills, including ability to type

PREFERRED QUALIFICATIONS:

• Multi-lingual capabilities preferred, but not required
• Strong communication and problem-solving skills
• Technologically savvy is a plus
• Prior experience as a Community Health Worker, Peer Support Specialist or similar role 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. All individuals (including current employees) selected for a position will undergo a background check appropriate for the position's responsibilities

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