Clinical Outreach Specialist
Core
Serve as a clinical bridge for high-risk patients between hospital discharge and home recovery, preventing readmissions and ER visits through telephonic care coordination.
Role type
Senior IC clinical outreach specialist (case management)
Builds
Post-discharge care transitions and population health interventions
Domain
Healthcare / Case Management
Deliverable
physical/clinical work
Required skills
medication reconciliation, patient education, care gap identification, EHR documentation, clinical assessment, care coordination, performance metrics management
Preferred skills
Value Based Care experience, Case Management certification, experience with diverse/underserved populations
Technologies
Electronic Health Records (EHRs), population health tools
Responsibilities
Conduct targeted patient outreach (inbound/outbound) to close care gaps; Deliver high-touch engagement for high-risk patients; Document interventions and assessments across multiple EHRs; Collaborate with primary care practices on Transitional Care Management and other initiatives; Address patient reluctance through empathy and active listening.
Seniority
Mid-level, hands-on IC