Clinical Outreach Specialist

Team: Patient & Practice Solutions

Location: Remote, United States

Commitment: Full Time

Workplace Type: remote

Primary Duties

Patient Outreach & Coordination: 

Conduct targeted patient outreach to address and close care gaps, ensure timely care transitions, and immediate follow-up as needed. Daily responsibilities will include both inbound and outbound calls.

Deliver high-touch engagement for high-risk patients to prevent readmissions through post-discharge follow-up, medication reconciliation, and care coordination (i.e. Labs, screenings, and follow-up appointments).

Document interventions, assessments, and medication reconciliation across multiple EHRs while maintaining accuracy and compliance.

Provide patient education and assess eligibility for concurrent programsPersistently address patient reluctance or hesitation through education, empathy, and active listening.

Meet and sustain performance metrics 

Practice Collaboration & Relationship Management:

Collaborate with Practices to support interventions such as Transitional Care Management (TCM), Osteoporosis Management in Women (OMW), ED follow-ups, and other care gap initiatives. 

Serve as a clinical resource to foster collaboration and alignment with Aledade’s clinical programs.

Collaborate across teams to support patient engagement strategies and organizational goals.

Address challenges proactively, adapting strategies as needed and identifying areas for process improvement.

Minimum Qualifications

• Certificate or Diploma in Practical Nursing or Associate Degree in Nursing (ADN)

• Current and unrestricted LPN license

• Minimum of 2 years clinical experience in case management or discharge planning

• Experience with telephonic patient outreach and clinical assessments

• Demonstrated ability to prioritize and manage high-acuity cases

• Excellent communication and interpersonal skills 

• Experience with electronic health records (EHRs) and population health tools

• Critical thinking and clinical judgement in complex and rapidly changing environments

• Adaptability and resilience in a fast-paced, evolving healthcare setting

• Ability to work both independently and as part of an interdisciplinary team

Preferred Qualifications

Experience in a remote environment

Active, unrestricted Registered Nurse (RN) license; Valid Compact RN license 

Experience in Value Based Care

Certification in Case Management (CCM, ACM) or Care Transitions

Experience working with diverse and underserved populations

Physical Requirements

• Prolonged periods of sitting at a desk and working on a computer.