Clinical Outreach Specialist

As a Clinical Outreach Specialist, you will serve as a vital clinical bridge for high-risk patients, utilizing your clinical expertise to navigate the critical window between hospital discharge and home recovery. In this high-impact, telephonic role, you will perform complex medication reconciliations, identify looming clinical red flags, and proactively close care gaps to prevent unnecessary ER visits and readmissions. By blending empathetic patient education with data-driven population health tools, you will empower patients to manage their health effectively while collaborating directly with primary care practices to ensure no one falls through the cracks of the healthcare system.

We are flexible with respect to geographic location, and the ideal candidate will be comfortable working remotely/work from home across US time zones.

Primary Duties
Patient Outreach & Coordination:

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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.

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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).

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

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

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Meet and sustain performance metrics

Practice Collaboration & Relationship Management:

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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.

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

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

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

Minimum Qualifications
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Certificate or Diploma in Practical Nursing or Associate Degree in Nursing (ADN)

- Current and unrestricted LPN license

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

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Experience with telephonic patient outreach and clinical assessments

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Demonstrated ability to prioritize and manage high-acuity cases

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Excellent communication and interpersonal skills

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

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Critical thinking and clinical judgement in complex and rapidly changing environments

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

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

Preferred Qualifications
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Experience in a remote environment

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

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Experience in Value Based Care

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

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Experience working with diverse and underserved populations

Physical Requirements
- Prolonged periods of sitting at a desk and working on a computer.