Clinical Community Health Worker

ABOUT US A Specialty Path to Good Health Upperline Health is the nation's largest provider group dedicated to lower extremity, wound and vascular care. Founded in 2017 with the ambitious goal of transforming specialty care, Upperline Health is a pioneer in bringing value-based care models into specialty care. Upperline delivers a more efficient path for patients to receive consistent and effective treatment for chronic illnesses. Triage is temporary. Treatment is transformative. Upperline Health providers coordinate patients' care among a team of specialists -- physicians, advanced practice providers, care navigators, pharmacists, dieticians, and social workers for integrated treatment that addresses patients' immediate and long-term health needs. We put patients at the center of value-based care. About the Clinical Community Health Worker The Community Health Worker (CHW) is a frontline member of the Upperline Plus care team, responsible for managing a panel of patients through in-home visits and facilitating virtual visits with a Nurse Practitioner (NP). This role bridges the gap between clinical care and the home environment, ensuring patients in rural and underserved areas receive consistent, coordinated, and accessible health care. The CHW serves as the "eyes and hands" for the NP, gathering information, supporting technology use, and building trusted relationships with patients and their families. What You'll Do Home Visits & Patient Panel Management • Conduct regular scheduled home visits to an assigned panel of patients, following a defined visit cadence based on patient acuity and care plan needs • Perform basic health assessments during visits, including vital signs (blood pressure, pulse, temperature, oxygen saturation, weight), medication reconciliation, and home safety/environmental checks • Observe and document changes in patient condition, living situation, SDOH needs/health disparity needs, or caregiver support, and escalate concerns to the clinical care team promptly • Build rapport and trust with patients and families to support engagement in their care plan Facilitating Virtual NP Visits • Set up and manage telehealth equipment (tablet, camera, connectivity devices) in the patient's home to enable real-time virtual visits with the NP • Act as the NP's "hands" during virtual visits — assisting with physical exam maneuvers as directed (e.g., positioning a stethoscope or otoscope, guiding the camera), and relaying findings • Ensure patients are prepared for virtual visits (appointment reminders, gathering medications/records, addressing questions or anxiety about the technology) • Trouble-shoot basic technical issues with telehealth devices and internet connectivity; escalate persistent issues to IT support Care Coordination & Documentation • Document all visit findings, vital signs, and observations accurately and promptly in the electronic health record (EHR) • Communicate patient status updates, concerns, and care plan progress to the NP and broader care team on a regular basis • Help coordinate follow-up appointments, referrals, transportation, and connections to community resources (food assistance, home health, social services, etc.) • Support medication adherence through education, pill organization assistance, and refill reminders Patient & Community Education • Provide basic health education on chronic disease management (e.g., diabetes, hypertension, COPD), health literacy support, fall prevention, and healthy lifestyle habits • Educate patients and families on how to use telehealth technology and when/how to reach the care team between visits • Serve as a cultural and community liaison, helping the clinical team understand patients' home environment, social determinants of health, and barriers to care Qualifications of the Clinical Community Health Worker • High school diploma or equivalent; Community Health Worker certification (or willingness to obtain within 90 days of hire, where state-certified programs exist) • Valid driver's license, reliable vehicle, and willingness to travel daily within a rural service area, including to remote or hard-to-reach locations • Comfort using tablets, apps, and basic telehealth/videoconferencing technology • Demonstrated ability to independently research and identify local, regional, and national resources addressing social determinants of health (SDOH), including resources related to food insecurity, housing, transportation, financial assistance, utilities, healthcare access, and other social needs • Ability to assess a patient's individual circumstances and social needs and determine which resources, programs, or services are most appropriate for their specific situation • Ability to translate complex program requirements and social-service processes into clear, practical, and patient-friendly guidance • Knowledge of mandated reporting requirements and ability to recognize situations involving suspected abuse, neglect, or exploitation, provided by or observed in working with patients • Ability to appropriately document and communicate concerns while maintaining patient confidentiality, professionalism, and adherence to organizational policies and reporting requirements • Strong interpersonal and communication skills; ability to build trust with diverse rural populations. Ability to collaborate effectively with community partners/agencies and advocate for patients when navigating social service systems • Ability to work independently in the field with minimal direct supervision Preferred • Prior experience in home health, medical assisting, EMT/paramedic work, or community outreach • Bilingual/multilingual skills relevant to the service area's population • Familiarity with EHR systems and basic clinical documentation • Existing ties to or knowledge of the local rural community Physical & Work Environment Requirements • Ability to travel extensively by car, including on rural/unpaved roads and in varying weather conditions • Ability to lift and carry a telehealth equipment bag (up to ~20 lbs) and basic supplies • Comfortable spending the majority of the workday in patients' homes rather than a clinical office setting • Flexibility to adjust visit schedules based on patient availability and urgent needs What Success Looks Like • Patients on the CHW's panel receive consistent, timely home visits per their care plan • Virtual NP visits run smoothly with minimal technical disruption • Care team receives accurate, timely updates that support proactive, coordinated care • Patients report improved trust, engagement, and satisfaction with their care Benefits Comprehensive benefit options include medical, dental and vision, 401K and PTO. Compensation Compensation is commensurate to compensation for similar positions in the region and based on prior training and experience Job Type: Full-time Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.