Outreach Support Specialist

PedIM Healthcare•Lecanto, FL

just now

About The Position

We are seeking a proactive and compassionate Outreach Support Specialist to join our Primary Care team! The Outreach Support Specialist is an integral member of the Outreach Team, working collaboratively with the Outreach Coordinator and Outreach Provider to support high-risk Medicare patients. This role focuses on executing daily outreach tasks that promote care continuity, reduce unnecessary hospital utilization, and enhance the overall patient experience.

Requirements

Excellent communication and interpersonal skills with a patient-first approach required.
Ability to manage multiple patients and tasks in a fast-paced, high-touch environment.
Strong organizational skills and follow-through.

Nice To Haves

Familiarity with EHR systems, hospital discharge processes, and SNF/ALF placement procedures preferred.
Clinical background (e.g., LPN, RN, MA, Social Work) or equivalent healthcare coordination experience preferred.
Knowledge of ACO workflows, Medicare population health management, and healthcare cost containment strategies preferred.
Experience in a healthcare setting, preferably in care coordination, case management, or a PCP office preferred.
Bilingual skills are a plus.

Responsibilities

Conduct outreach to patients with chronic conditions, recent hospitalizations, or frequent emergency room visits.
Confirm upcoming appointments, provide reminders, and assist with follow-up scheduling, including Transitional Care Management (TCM) and Emergency Room Follow-Up (ERFU) visits.
Assist in scheduling urgent or same-day appointments to help divert non-emergent cases from the ER or hospital.
Reinforce discharge instructions and educate patients on the appropriate use of primary care versus emergency services.
Contact external facilities—including hospitals, skilled nursing facilities (SNFs), and assisted living facilities (ALFs)—to gather discharge summaries, treatment updates, or care coordination details.
Accurately document all outreach activities and patient responses in the EMR and designated tracking tools.
Utilize and maintain outreach spreadsheets to monitor patient status, contact history, and scheduling progress.
Identify and flag patient barriers (e.g., transportation, medication access) and escalate issues requiring additional support.
Provide general education and direction to patients regarding available resources and care pathways.
Prepare and distribute outreach-related materials such as care plans, referral forms, resource packets, and patient mailers.
Respond to incoming calls on the hospital diversion line and assist in coordinating timely care as needed.
Communicate with external providers and facilities to relay routine updates and facilitate care coordination.
Collaborate with the Outreach Coordinator, Outreach Provider, and other internal departments to maintain aligned outreach efforts.
Escalate complex patient needs or urgent concerns to the Outreach Coordinator or appropriate clinical staff.
Complete other tasks assigned.