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Upward Health
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  • Clinical Solution Specialist, SDoH and Care C  

    - New York
    Company Overview: Upward Health is an in-home, multidisciplinary med... Read More
    Company Overview:

    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!

    Job Title & Role Description:

    The Clinical Solution Specialist, SDoH and Care Coordination is acutely focused on improving clinical, quality, and safety outcomes for patient populations with Social Determinants of Health and Care Coordination barriers. This role will work alongside a team of doctors, pharmacists, nurses, social workers, nurse practitioners, and clinical services leaders to develop evidence-based clinical Solutions, quality improvement strategies, assist in the design of patient care models, assess health risk outcomes, and facilitate team communication on clinical Solution(s) strategies. The Clinical Solution Specialist will have advanced knowledge and expertise in clinical Solution development and broad knowledge in the field of social determinants of health, behavioral health, and overall patient care management that supports the development of clinical strategy and processes, education of clinical operations teams, while also acting as a subject matter expert for the wider healthcare team.

    Skills/Requirements: Healthcare related bachelor's degreeProject Management certification, lean six sigma, and/or other related certifications preferredPreviously worked as a Community Health Worker, Peer Support Specialist, Licensed Clinical Social Work, Addiction Counselor, or other related clinical experience related to social determinants of health, mental health, substance use, and/or primary careSocial Determinants of Health and/or Care Coordination/Care Management solution development experience (i.e., workflows, system usage, staffing)Practical experience working within primary care, population health, mental health, substance use, and social determinants of healthClinical and non-clinical team education and training experienceKnowledge in z-codingExperience in Medicare and Medicaid reimbursement structuresProficiency in Electronic Medical Record (EMR) softwareAbility to travel to various Upward Health markets as neededProficient with current office technologies Experience using project management tools and methodologyExperience using process improvement tools such as Visio
    Key Behaviors:

    Collaboration & Teamwork: Works effectively with an interdisciplinary healthcare team, leveraging diverse expertise to improve patient outcomes.Actively listens to team members and stakeholders, and integrates their feedback into Solution development. Problem Solving & Decision Making: Uses data analysis and clinical insights to inform decisions and develop effective solutions for improving Solution outcomes.Demonstrates the ability to identify issues, assess risks, and implement corrective actions. Communication & Influence: Communicates complex clinical concepts clearly to both internal and external stakeholders.Demonstrates active listening and empathy, particularly in engaging with patients or healthcare professionals regarding behavioral health and substance use issues.Effectively presents training materials and Solution updates to a variety of audiences, including patients, providers, and interdisciplinary teams. Adaptability & Flexibility: Adapts to changes in clinical solution needs, evolving best practices, regulatory or contractual requirements, or stakeholder expectations.Willingness to adjust to changing schedules and demands, including the flexibility to work occasional nights and weekends. Attention to Detail: Reviews medical records and clinical data with high attention to accuracy and compliance with regulations and standards (e.g., HEDIS measures, HIPAA).Ensures thorough documentation and synthesis of patient and solution data for reporting. Leadership & Accountability: Takes ownership of the development and ongoing refinement of clinical solutions.Responsible for meeting quality improvement metrics and patient outcomes associated with their solutions.Demonstrates leadership in clinical Solution training, ensuring all involved parties are educated on key aspects of the solution. Patient-Centered Care: Prioritizes the needs and outcomes of patients, particularly in the context of mental health, substance use, and social determinants of health (SDoH).Ensures that patient feedback and real-life outcomes are incorporated into the clinical solution's evolution. Efficiency & Time Management: Manages competing priorities and multiple stakeholder demands, ensuring deadlines are met and outcomes are achieved efficiently.Organizes workflows and schedules for solution implementation, training, and assessment in an effective manner.
    Competencies:

    Clinical Solution Development: Expertise in designing and implementing evidence-based clinical solutions, especially in behavioral health and substance use disorders.Ability to analyze patient data to identify opportunities for solution enhancements. Primary Care Knowledge: Detailed understanding of Provider / patient experience building and effective visit methods.Knowledge of problem identification and diagnosis code capture.Strong understanding of clinical care team collaboration to effectively provide whole-person care. Develop and implemented standardized workflows for developing primary and specialty care directories for more efficient patient resource support and navigation. Community Based Organization Experience: Experience in establishing care coordination workflows between primary care teams and community-based organizations (CBOs) to streamline referrals, track referral outcomes, close social detemrinant of health (SDoH) gaps, and improve patient outcomes through integrated pathways.Develop and implemented standardized workflows for developing community-based and social service directories for more efficient patient resource support and navigation. Social Determinants of Health (SDoH): Strong understanding of the impact of social factors such as socioeconomic status, environment, and community on patient health outcomes.Ability to integrate SDoH considerations into solution design and patient care. Regulatory Compliance & Accreditation: Proficiency in understanding and applying HEDIS measures, accreditation standards, and regulatory requirements related to healthcare Solutions.Ability to prepare and maintain documentation for audits, compliance, and quality assurance processes. Data Analysis & Reporting: Skilled in collecting, analyzing, and synthesizing clinical data, including health outcomes, patient satisfaction, and quality metrics.Proficient in creating actionable reports and presenting findings to leadership. Training & Education: Experience in creating training content and delivering educational Solutions for both clinical and non-clinical team members.Ability to assess learning needs and deliver customized training solutions to diverse audiences. Project Management: Familiar with project management tools and methodologies to plan, execute, and monitor the progress of clinical solution initiatives.Experience in coordinating timelines, resources, and stakeholder engagement to ensure the successful rollout of solutions. Technology Proficiency: Competence with Electronic Medical Records (EMR) systems and familiarity with healthcare-related software to enhance Solution delivery and data tracking. Experience with Salesforce or similar CRM systems a plus.Ability to utilize technology to improve solution outcomes and operational efficiency. Quality Improvement (QI): Knowledge implementing quality improvement initiatives.Familiar with measuring and reporting on quality metrics, including those related to patient safety, clinical outcomes, and solution effectiveness.
    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.

    Compensation details: 0 Yearly Salary

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  • Supervisor, Nursing Operations  

    - New Orleans
    Company Overview: Upward Health is an in-home, multidisciplinary med... Read More

    Company Overview:

    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 combating 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!

    Job Title & Role Description:

    The Supervisor, Nursing Operations plays a key leadership role in overseeing the day-to-day operations of the nursing team, including triage nurses, remote nurse care managers, and field-based nurses. This position ensures the delivery of high-quality, patient-centered care across all markets through clinical oversight, training, performance management, and workflow optimization.

    The Supervisor partners closely with Clinical Operations and interdisciplinary teams to support transitions of care, care plan development, proactive outreach, and triage functions. They are responsible for ensuring clinical protocols are followed, performance expectations are met, and that care is coordinated efficiently and effectively to drive improved patient outcomes.

    Responsibilities:

    Provide direct supervision, mentorship, and support to a team of nurses including Triage Nurses (TRNs) and Nurse Care Managers (NCMs).Oversee day-to-day team activities, ensuring timely outreach, triage follow-ups, and completion of assessments and care planning.Support transitions of care, including ED and inpatient discharge workflows, ensuring post-discharge follow-up standards are met.Monitor team productivity, call volumes, and documentation to ensure compliance with internal standards and payer requirements.Analyze performance data, generate reports, and use insights to drive continuous improvement and operational excellence.Partner with leadership to develop training content and ensure onboarding, ongoing education, and professional growth of nursing staff.Collaborate cross-functionally with clinical leadership, providers, and other departments to enhance patient care delivery.Maintain consistency in workflows and lead performance evaluations, coaching, and corrective actions as needed.Ensure compliance with clinical guidelines, regulatory requirements, and quality standards (e.g., URAC, NCQA).

    Skills Required:

    Unrestricted RN license in the state(s) of care management activities a minimum requirement.At least 5 years of experience in a healthcare setting with demonstrated leadership in nursing operations, care coordination, or telehealth/triage roles, including oversight of clinical workflows, team performance, and quality improvement initiatives. Certified Case Manager (CCM) or similar care management certification is preferred but not required.Strong understanding of care transitions, discharge planning, and telephonic triage.Experience with supervisory responsibilities, including performance management, coaching, and training.Strong organizational and time management skills, with the ability to prioritize and meet deadlines.Ability to maintain professional boundaries with both team members and patients.Cultural humility and the ability to engage with diverse patient populations.Strong problem-solving skills and the ability to manage clinical escalations.

    Key Behaviors:

    Leadership & Mentorship:

    Builds high-functioning teams, provides clear direction, and fosters professional development.Ensures the team remains motivated, informed, and well-prepared to deliver high-quality patient care.

    Collaboration & Teamwork:

    Works effectively with cross-functional teams to coordinate care and optimize patient outcomes.Collaborates with Clinical Operations leadership to address challenges and improve processes.

    Efficiency & Time Management:

    Demonstrates strong organizational skills and the ability to prioritize tasks, ensuring timely patient outreach and follow-up care.

    Patient-Centered Focus:

    Always advocates for the best interests of patients, ensuring care plans are clearly communicated, implemented, and followed through.

    Adaptability:

    Thrives in a fast-paced, dynamic environment, showing flexibility and responsiveness to the evolving needs of the organization and patients.

    Data-Driven Decision Making:

    Utilizes data to drive operational improvements, assess team performance, and ensure the highest quality of care for patients.

    Effective Communication:

    Engages in open, respectful communication with staff, patients, and other stakeholders.

    Competencies:

    Clinical Expertise:

    In-depth knowledge of triage protocols and telephonic care coordination.

    Supervisory Skills:

    Ability to manage a team of nurses, including conducting performance evaluations, training new hires, and fostering professional growth.

    Critical Thinking & Problem Solving:

    Ability to identify gaps in care or workflow inefficiencies, applying critical thinking to resolve issues.

    Operational Excellence:

    Strong understanding of workflow management, team productivity, and patient care optimization.

    Technology Proficiency:

    Experience using various technology tools (EHR, CRM, Microsoft Excel) to document patient care, track team performance, and generate reports.

    Communication & Relationship Building:

    Skilled in both written and oral communication, effectively conveying information to diverse groups, including patients, families, and healthcare providers.

    Cultural Competence:

    Demonstrates sensitivity to cultural differences and engages with patients and colleagues in a respectful and inclusive manner.

    Outcome-Focused:

    Committed to achieving positive clinical and operational outcomes through effective management and coordination of triage care.

    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.



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  • Community Outreach Specialist  

    - Holbrook
    Job DescriptionJob DescriptionUpward Health is an in-home, multidiscip... Read More
    Job DescriptionJob 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?

    The Outreach Specialist (OS) plays a critical role at Upward Health. The OS is the first point of contact with our company for our patients. We count on the OS to make an excellent first impression and to be able to effectively communicate our service offering to patients. The goal of this role is to inform patients about our services and to help them get started. Our services are focused on improving a patient’s health, and the OS helps him or her take that first step.

    The OS manages a caseload and utilizes a range of strategies to connect with our potential patients. Phone is our top strategy, and it’s important that our OS is comfortable and confident communicating by phone. There may be times that field-based approaches are utilized as well. The OS should be prepared to use whatever strategy is most effective. The OS reports to our Outreach Manager.

    Applicants tend to be individuals who would describe themselves as a “people person.” You enjoy talking to new people – whether by phone or in person. You might have taken past roles in sales or retail to satisfy this interest. You also want to help others. You may even have past experience helping others with their health, whether through a previous job or in your personal life. You communicate well. You enjoy a fast-paced environment. You are flexible and like when each day is different. You are driven by reaching goals, and you like a challenge. We are looking forward to meeting you!

    KEY RESPONSIBILITIES:

    Conduct 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 processManage a personal caseload of patients and ensure that each assigned patient is contacted using the most effective strategyOn an as-needed basis, interact with enrolled patients to ensure ongoing engagement or to deliver additional community-based touchpointsParticipate in weekly team meetings focused on ongoing education and improvementAccurate and timely documentation in our company‘s software system

    KNOWLEDGE, SKILLS & ABILITIES:

    Verbal communication skillsPersuasivenessFlexibilityDedication and resilienceEnergeticAttention to detailAbility to multitaskBoth independence and teamworkSolid computer skills

    QUALIFICATIONS:

    Ability to quickly establish trust and build a relationship with patientsAbility to clearly communicate Upward Health’s service offering and valueActive listening skills and genuine compassion for othersQuick thinking and ability to respond to questions and objections Organized and self-motivated Ability to work independently and meet established goalsEnjoys 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 workMust have reliable transportation to perform essential outreach functionsMust be fluent in English. Spanish speaking a PLUS!Able to work flexible hours, including occasional night/weekend workMinimum of 3 years of work experience with focus on those who have sales, healthcare, or past outreach experience.

    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.


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