Clinical Outreach Specialist

Aledade PBC

58d • Remote

About The Position

The Clinical Outreach Specialist serves as a clinical bridge for high-risk patients during the period between hospital discharge and recovery at home. This telephonic role uses clinical expertise and population health tools to support safe transitions, identify clinical concerns, close care gaps, and help prevent avoidable emergency department visits and readmissions. The specialist provides empathetic patient education and works with primary care practices to support continuity of care. The role is geographically flexible and is suited to someone comfortable working remotely from home across U.S. time zones.

The position involves inbound and outbound outreach, post-discharge follow-up, medication reconciliation, care coordination, EHR documentation, patient education, and collaboration with practices and internal teams. The specialist also works to address patient reluctance, meet performance metrics, and identify opportunities to improve processes.

Requirements

• Certificate or diploma in Practical Nursing or an Associate Degree in Nursing (ADN).
• Current and unrestricted LPN license.
• At least 2 years of 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 judgment in complex, rapidly changing environments.
• Adaptability and resilience in a fast-paced, evolving healthcare setting.
• Ability to work independently and as part of an interdisciplinary team.

Nice To Haves

• Experience working remotely.
• 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.

Responsibilities

• Conduct targeted patient outreach to close care gaps, support timely care transitions, and arrange immediate follow-up when needed; handle inbound and outbound calls.
• Engage high-risk patients after discharge to help prevent readmissions through follow-up, medication reconciliation, and coordination of labs, screenings, and appointments.
• Document interventions, assessments, and medication reconciliations accurately and compliantly across multiple EHRs.
• Provide patient education and assess eligibility for concurrent programs.
• Address patient reluctance or hesitation using education, empathy, and active listening.
• Meet and sustain performance metrics.
• Collaborate with practices on Transitional Care Management (TCM), Osteoporosis Management in Women (OMW), emergency department follow-ups, and other care-gap initiatives.
• Serve as a clinical resource supporting collaboration and alignment with Aledade’s clinical programs.
• Collaborate across teams to support patient engagement strategies and organizational goals.
• Address challenges proactively, adapt strategies, and identify process-improvement opportunities.

Benefits

• Flexible work schedules and remote work options for many roles.
• Health, dental, and vision insurance paid up to 80% for employees, dependents, and domestic partners.
• 21 days of PTO in the first year.
• Two paid volunteer days and 11 paid holidays.
• 12 weeks of paid parental leave for all new parents.
• Six-week paid sabbatical after six years of service.
• Educational Assistant Program and Clinical Employee Reimbursement Program.
• 401(k) with up to 4% match.
• Stock options.

What This Job Offers

• Job Type: Full-time
• Education Level: Associate degree