Care Experience Specialist

Overview The Care Experience Specialist (CES) is the human layer that makes our model work. You are the trusted connection and translator between a Family Member (FM) – the people we serve – and everything CINQCARE and Grace at Home can offer. You will build relationships and support a defined group of people in your local community, owning those relationships from first outreach through ongoing connection over time. You will proactively reach out to people who may not be expecting support, meet them at home, at their doctor's office, and in the community spaces where they already spend time, and stay accessible when they need you. You will help reconnect people to care through consistent follow-ups, support after hospital visits, and steady, reliable presence. You are accountable for helping Family Members – especially those with high or critical needs – move from disconnection into an active care pathway by recognizing when support is needed and ensuring timely handoff and follow‑through with the care team. While you are not a clinician, you play a critical role in making care happen. You surface needs, build trust, and coordinate closely with nurses, care managers, and providers to ensure the right care is activated at the right time. You help Family Members understand what care is available, what to expect, and why it matters – translating healthcare into something human, clear, and actionable. Duties & Responsibilities Family Member Relationship Management Own and manage a defined panel of Family Members, establishing the relationship from first introduction through sustained and ongoing contact, follow‑through, and retention built across months and years. Proactively initiate contact with individuals who may not be actively seeking support and build meaningful, ongoing relationships through persistent and compassionate engagement strategies. Prioritize outreach and engagement efforts across an active caseload by identifying Family Members at risk of disengagement and ensuring timely follow‑up and intervention. Serve as a consistent, trusted, and accessible presence for Family Members – someone they remember between visits and who listens for what they are trying to say, not only what they have said. Community-Based Outreach & Engagement Conduct community‑based outreach and engagement activities through home visits, provider offices, community centers, shelters, churches, and other community settings to ensure consistent visibility, accessibility, and support. Go out: wherever the relationship needs to happen – home visits, doctor's offices, community centers, shelters, churches – ensuring engagement occurs on the Family Member's terms and in the spaces where they already spend time. Show up as a member of the community, not a visitor to it, building trust with Family Members and the people and places they belong to, including local organizations, faith communities, and trusted community voices. Convert first outreach conversations into working relationships over time – persistent without being pushy – understanding who needs attention now, who is at risk of disengaging, and how to prioritize across a full caseload. Barrier Identification & Resource Coordination Identify and address barriers impacting health and stability – including housing, food insecurity, transportation, benefits access, and appointment adherence – by coordinating appropriate resources, referrals, and follow‑up services. Help Family Members navigate the social and logistical challenges that get in the way of care, working closely with care teams to ensure barriers are identified early and addressed before they lead to disengagement or avoidable utilization. Care Transitions & Continuity Support Family Members transitioning from hospitals and emergency rooms back into the community by reinforcing discharge plans, confirming follow‑up appointments, and reducing gaps in care that may contribute to avoidable readmissions. Build continuity where the system tends to drop off – reconciling discharge plans, confirming follow‑up care, and staying connected until the Family Member is successfully stabilized in the appropriate level of care. Clinical Team Collaboration & Escalation Collaborate closely with primary care practices, practice managers, nurses, care managers, and interdisciplinary care teams to improve care coordination, communication, and resource utilization for shared Family Members. Serve as a trusted and embedded partner within assigned primary care offices, contributing to stronger practice relationships and improved Family Member engagement outcomes. Support connection to care by identifying early risks or barriers and ensuring timely handoff to clinical teams – the critical step that enables Family Members to access and stay engaged in care. As a nonclinical team member, elevate risks to licensed care professionals promptly, tracking progress and staying connected until the Family Member is appropriately supported. When a Family Member joins a Nurse Practitioner for an Annual Wellness Visit or other clinical encounter, provide support and accompany as appropriate – because your presence can make the clinical visit possible. Judgment, Boundaries & Professional Standards Navigate complex and sensitive situations with sound judgment, determining when to intervene directly, elevate, or refer, while maintaining trust, setting appropriate boundaries, and upholding CINQCARE and Grace at Home standards of care. Hold complex situations with composure and take rejection as information, not as a verdict – remaining emotionally resilient and self‑aware in a role that is meaningful and sometimes heavy. Documentation & Communication Maintain accurate, timely, and actionable documentation of all Family Member interactions, interventions, and outcomes within organizational systems to support continuity of care and effective team collaboration. Bring signals from the field back to leadership – what Family Members need, what is working, and what is not – to contribute to continuous improvement of care delivery and model effectiveness. Communicate insights, trends, and challenges observed in the field to the care team and management to support ongoing quality improvement efforts. Team & Learning Participate in team debriefs, peer support activities, and collaborative learning opportunities that promote shared knowledge, emotional resilience, and the sustainability of high‑intensity engagement work. Share effective approaches and field‑developed solutions with the broader team so that others benefit from what you learn – because the best answers in this work come from the field. Qualifications Education High school diploma or equivalent required; Associate’s or Bachelor’s degree in Social Work, Human Services, Public Health, Healthcare Administration, Psychology, Community Health, or a related field preferred. Relevant lived experience, community involvement, and demonstrated relationship‑building within the local community may be considered in lieu of formal education. Experience Experience in community outreach, care coordination, patient navigation, social services, community health work, peer support, case management, or related consumer‑facing roles preferred. Experience supporting individuals navigating chronic health conditions, housing instability, food insecurity, transportation barriers, behavioral health concerns, or frequent emergency room utilization preferred. Active community presence – leading a neighborhood group, faith community, civic organization, youth program, or any setting where trust has been built with people at the local level and connections to resources have been made. Demonstrated ability to build trust and maintain relationships within diverse communities through direct engagement, advocacy, and consistent follow‑through. Experience managing multiple relationships, prioritizing outreach efforts, and maintaining ongoing follow‑up in a fast‑paced or field‑based environment preferred. Consumer‑facing or community organizing experience where problems were solved without a full playbook and engagement happened in people's world rather than asking them to come to you. Bilingual fluency in a language commonly spoken within the local community is a strong plus. Certifications Community Health Worker (CHW), Peer Support Specialist, Certified Care Manager (CCM), Care Coordination or Case Management, CPR/First Aid, or other healthcare or community‑based certifications preferred but not required. Valid driver's license and reliable transportation may be required based on market and community needs. Technical Skills Ability to maintain accurate, timely, and detailed documentation within electronic systems and care management platforms. Proficiency with Microsoft Office Suite and mobile technology, including email, scheduling, documentation systems, and virtual communication tools. Ability to manage caseloads, track outreach activities, and coordinate follow‑up across multiple Family Members and care teams. Who You Are Someone Family Members remember between visits – you listen for what a person is trying to say, not only what they have said. Comfortable in hard moments: you hold complex situations with composure and take rejection as information, not as a verdict. A person who follows through – the relationship holds because you show up, not just because you called. Emotionally resilient and self‑aware – this work is meaningful and sometimes heavy, and you know the difference between sustainable and not. Organized enough to build rhythms that make the work hold. Strong relationship‑building and interpersonal skills with the ability to establish trust and credibility over time. Demonstrated empathy, emotional intelligence, and cultural sensitivity when working with diverse populations and complex life circumstances. High level of accountability, reliability, and follow‑through in managing commitments and supporting Family Members. Collaborative team player who values shared learning, continuous improvement, and community‑centered care. Our Values In This Role Trusted – Family Members open the door because they know you will follow through. You do what you say, every time, with every person on your panel. When you fall short, you own it directly and make it right. Trust is not a quality you have. It is something you build, visit by visit, over time. Empathetic – you understand the experience of the people you serve without projecting onto them or pitying them. You know that being hard to reach is not the same as not caring, and you stay curious about why rather than writing someone off. Committed – you stay engaged with a Family Member through setbacks, not just early momentum. When someone goes quiet or pushes back or disappears, you do not move on – you adjust and come back. Humble – you ask for guidance on hard calls rather than improvising and hoping. You treat what you learn from Family Members as some of the most valuable knowledge you carry and bring it back to the team. Creative – you find the approach that fits the person in front of you, not the one the playbook assumed. When the standard way is not working, you try something different, and when you invent something better, you share it. Community Minded – you show up as a member of the community, not a visitor to it. You know the community well enough to know who the trusted voices are, and you work with them rather than around them. Working Conditions & Physical Requirements This role operates on a shift rotation that includes some evening hours and weekend coverage. This position requires in‑home, assisted living, and community-based work. The role requires frequent travel for Family Member visits in all types of weather conditions. Work may be performed in settings with conditioned air, artificial light, and open workspaces, as well as in community settings including homes, shelters, churches, and provider offices. Requirements include: ability to travel frequently by car and/or public transportation; ability to communicate with Family Members, care teams, vendors, and co‑workers in person and over devices; regular use of telephone and email for communication; ability to sit or stand for extended periods; ability to receive and prepare or inspect documents; ability to lift up to 50 lbs. occasionally; good manual dexterity for use of common office and mobile equipment; ability to understand and utilize management reports and other documents. Benefits Compensation and benefits reflect the scope and difficulty of this role and are calibrated to market, tenure, and individual experience. Grace at Home provides all employees working an average of 30+ hours/week with a comprehensive benefits package including the option to enroll in healthcare benefits. The cost of healthcare is shared between the company and the employee. Equal Opportunity & Reasonable Accommodation Statement Grace at Home is an Equal Opportunity Employer committed to creating an inclusive environment for all employees. We provide equal employment opportunities to all individuals regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected characteristic under applicable law. #J-18808-Ljbffr