Clinical Community Health Worker

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.

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.

• 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 escalated concerns to the clinical care team promptly
• Build rapport and trust with patients and families to support engagement in their care plan

• 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; escalated persistent issues to IT support

• 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

• 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