Clinical Outreach Specialist

The role

You will act as a clinical bridge for high-risk patients between hospital discharge and home recovery. The role is telephonic and focuses on medication reconciliation, closing care gaps and preventing readmissions, working with primary care practices.

What you will do

• Conduct targeted outreach to close care gaps and ensure timely care transitions
• Deliver high-touch engagement for high-risk patients to prevent readmissions
• Perform post-discharge follow-up, medication reconciliation and care coordination, including labs, screenings and follow-up appointments
• Document interventions, assessments and medication reconciliation across multiple EHRs
• Provide patient education and assess eligibility for concurrent programs
• Address patient reluctance or hesitation through education, empathy and active listening
• Meet and sustain performance metrics
• Collaborate with practices on Transitional Care Management, Osteoporosis Management in Women, ED follow-ups and other care gap initiatives
• Serve as a clinical resource for Aledade's clinical programs
• Address challenges proactively and identify areas for process improvement

Required qualifications

• Certificate or Diploma in Practical Nursing or Associate Degree in Nursing (ADN)
• Current and unrestricted LPN license; valid Compact 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, rapidly changing environments
• Adaptability and resilience in a fast-paced healthcare setting
• Ability to work both independently and as part of an interdisciplinary team
• Prolonged periods of sitting at a desk and working on a computer

Nice to have

• 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

Benefits

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

Before you apply

• The role requires an LPN or RN license, so candidates need a current, unrestricted license that the posting names
• Equity compensation and an annual performance bonus or incentive are part of the offer

About the company

Aledade PBC is a public benefit corporation founded in 2014 that empowers independent primary care. It is described as the largest network of independent primary care in the country and works on value-based contracts with health plans.