Clinical Outreach Specialist

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 programs.

Persistently address patient reluctance or hesitation through education, empathy, and active listening.

Meet and sustain performance metrics 

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.

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

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