Clinical Outreach Specialist

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 conc