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!

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 degree
• Project Management certification, lean six sigma, and/or other related certifications preferred
• Previously 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 care
• Social 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 health
• Clinical and non-clinical team education and training experience
• Knowledge in z-coding
• Experience in Medicare and Medicaid reimbursement structures
• Proficiency in Electronic Medical Record (EMR) software
• Ability to travel to various Upward Health markets as needed
• Proficient with current office technologies 
• Experience using project management tools and methodology
• Experience 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.

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