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:
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
Practice Collaboration & Relationship Management:
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.
Minimum Qualifications
Certificate or Diploma in Practical Nursing or Associate Degree in Nursing (ADN)
Current and unrestricted 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 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
Preferred Qualifications
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
Physical Requirements
Prolonged periods of sitting at a desk and working on a computer.
Who We Are:
Aledade PBC, a public benefit corporation, exists to empower the most transformational part of our health care landscape - independent primary care. We were founded in 2014, and since then, we've become the largest network of independent primary care in the country - helping practices, health centers and clinics deliver better care to their patients and thrive in value-based care. Additionally, by creating value-based contracts across a wide variety of health plans, we aim to flip the script on the traditional fee-for-service model. Our work strengthens continuity of care, aligns incentives and ensures primary care physicians are paid for what they do best - keeping patients healthy. If you want to help create a health care system that is good for patients, good for practices and good for society - and if you're eager to join a collaborative, inclusive and remote-first culture - you've come to the right place.
What Does This Mean for You?
At Aledade PBC, you will be part of a creative culture that is driven by a passion for tackling complex issues with respect, open-mindedness and a desire to learn. You will collaborate with team members who bring a wide range of experiences, interests, backgrounds, beliefs and achievements to their work - and who are all united by a shared passion for public health and a commitment to the Aledade mission.
In addition to time off to support work-life balance and enjoyment, we offer the following comprehensive benefits package designed for the overall well-being of our team members:
Flexible work schedules and the ability to work remotely are available for many roles
Health, dental and vision insurance paid up to 80% for employees, dependents and domestic partners
Robust time-off plan (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
And much more!
At Aledade PBC, we don’t just accept differences, we celebrate them! We strive to attract, develop and retain highly qualified individuals representing the diverse communities where we live and work. Aledade is committed to creating a diverse environment and is proud to be an equal opportunity employer. Employment policies and decisions at Aledade are based on merit, qualifications, performance and business needs. All qualified candidates will receive consideration for employment without regard to age, race, color, national origin, gender (including pregnancy, childbirth or medical conditions related to pregnancy or childbirth), gender identity or expression, religion, physical or mental disability, medical condition, legally protected genetic information, marital status, veteran status, or sexual orientation.
