About the role:

This is a hybrid role with 75% remote office time and 25% field-based time

Key Responsibilities:

• Assess, evaluate, and provide for the ongoing monitoring of patient care coordination and delivery that results in optimized quality, clinical and financial outcomes
• Complete comprehensive assessments and develops care plans utilizing clinical expertise to evaluate the patients need for Upward Health and additional services
• Develop a relationship of safety and trust with transparent communication between the patient, caregivers, and the care team
• Identify, acknowledge, and advocate for the needs of the patient  
• Build a patient-centric care plan and environment that incorporates the needs of the patient  
• Review the patient diagnoses and facilitate the coordination of treatment plans of the PCP, specialists, and interdisciplinary care team – Attend Interdisciplinary Team (IDT) rounds
• Evaluate patient outcomes with respect to the medical record, patient and family history and available healthcare utilization information
• Continuously monitor and update care plans and coordinate care across providers
• Educate patients and families about treatment plans and options
• Accurately document and submit medical documentation
• Maintain knowledge of diagnoses, signs and symptoms of disease, standard therapy protocols derived from evidence-based outcomes, medications, and warning signs of non-optimal patient outcomes 
• Provide guidance and support to patients and families inclusive of community-based support programs
• Review results from medical tests (lab, imaging, etc.) and ensure visibility across all care providers including escalation of abnormal or out-of-range findings
• Implement physician orders – ensuring a linkage between all care providers throughout a patient’s episodes of care
• Communicate patient progress by conducting regular interdisciplinary meetings and evaluations, disseminating results and obstacles to the healthcare team and family
• Function as a resource for non-clinical staff including first point of contact for patient triage and with escalation to the provider(s) as needed
• Coordinate community resources, with emphasis on medical, behavioral, and social services 
• Apply case management standards, maintains HIPAA standards and confidentiality of protected health information, and reports critical incidents and information regarding quality-of-care issues
• Meet with patients in their homes, worksites, physician’s offices, or hospital to provide management of services
• Participate with other care team members in regular or special meetings such as Clinical rounds
• Perform other duties as assigned

Knowledge, Skills and Abilities:

• Interpersonal savvy, with the demonstrated ability to interact with and influence people to establish trust and build strong relationships
• A high sense of urgency and can-do attitude required for a role at a start-up company

· 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 conduct written and oral instructions
• Ability to exercise judgment in the application of professional services

Required Qualifications:

• Unrestricted registered nursing license in the state(s) of care management activities a minimum requirement
• Travel to patient’s home, provider’s office, hospitals, etc., required with dependable car; This is a hybrid role with 75% remote office time and 25% field-based time
• Demonstrated expertise in care management and coordination across all healthcare providers, patient, and caregivers
• Experience with completing real-time documentation in EHR and/or Care Management systems
• Ability to effectively communicate across a multitude of key care partners
• Ability to motivate patients and caregivers to follow care plans and optimize self-care potential
• Excellent documentation skills with the ability to manage multiple patient cases
• Sound critical thinking to assess, analyze and monitor outcomes to recommend the optimal plan of care
• Computer literacy and ability to effectively communicate within the business structure

Preferred Qualifications:

• 3+ years of care management experience in an outpatient setting preferred 
• 3+ years in a hospital, health plan or related healthcare business entity also considered 
• Experience serving the Medicare, Medicaid, and Duals population
• Proven experience working independently seeing patients in the community

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