Clinical Outreach Specialist, Remote

Aledade is a physician-led public benefit corporation and national leader in value‑based care. We help primary care organizations deliver better patient outcomes and thrive financially by keeping people healthy. Through our accountable care organizations, over 3,000 primary care partners in 46 states and the District of Columbia share in the rewards of improved care for over 3 million patients — supported by advanced insights, AI‑driven technology, personal coaching, policy expertise and 200+ value-based contracts. To learn more, visit www.aledade.com or follow us on LinkedIn, X, Facebook, Instagram and YouTube.

As a Clinical Outreach Specialist, you will serve as a vital clinical bridge for high-risk patients, utilizing your nursing 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.

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 programsPersistently 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. Other duties as assignedWe are flexible with respect to geographic location, and the ideal candidate will be comfortable working remotely/work from home across US time zones.