The Clinical Patient Outreach Specialist is responsible for engaging patients through telephone, text, patient portal, and other communication methods to promote preventive health screenings, improve chronic disease management, and support value-based care initiatives. This role works collaboratively with clinic staff and payors to identify care gaps, educate patients, schedule recommended services, and improve patient health outcomes while meeting quality performance measures.
Essential Duties & Responsibilities
• Conduct outbound outreach to patients due for preventative screenings, immunizations, annual wellness visits, and chronic disease follow-up appointments.
• Take inbound calls when patients return phone calls.
• Schedule patient appointments directly into clinics EMR, following provider scheduling rules and identify reason for visit.
• Educate patients on the importance of preventative care and chronic disease management.
• Document all patient interactions accurately within the electronic health record (EHR).
• Coordinate with providers, nurses, medical assitants, and referral coordinators to ensure continuity of care.
• Monitor patient compliance with care plans and follow up on missed appointments or incomplete screenings.
• Assist patients in overcoming barriers to care by identifying transportation, finanical, or social needs and connecting them with appropriate resources.
• Reconcile appointments daily to identify patient arrival and if clinic staff closed gap in care.
• Work collaboratively with Target Health and clinic team.
• Maintain patient confidentiality and comply with HIPAA regulations.
• Support quality improvement initiatives aimed at improving HEDIS, STAR, MIPS, and other value-based performance measures.
• Participate in team meetings, workflow improvement activities, and ongoing training.
Required Qualifications:
• High school diploma or equivalent required.
• Certified Medical Assistant (CMA), Licensed Practical Nurse (LPN), Registered Nurse (RN), or equivalent clinical experience preferred.
• Minimum of one year of experience in a medical office, population health, care coordination, or patient outreach.
• Knowledge of preventative care guidelines and chronic disease management.
• Experience using electronic health record (Athenahealth experience preferred).
• Excellent verbal and written communication skills.
• Strong customer service and patient engagement skills.
• Ability to work independently while managing multiple priorities.
• Proficient with Microsoft Office and basic computer applications.
Preferred Qualifications:
• Experience in value-based care or accountable care organizations (ACO).
• Familiarity with HEDIS, CMS quality measures, STAR ratings, and MIPS reporting.
• Experience with Chronic Care Management (CCM), Transitional Care Management (TCM), and Remote Patient Monitoring (RPM).
• Bilingual (English/Spanish) preferred.
Knowledge, Skills, & Abilities:
• Excellent interpersonal and motivational interviewing skills.
• Ability to build trust and encourage patient participation in preventative care.
• Strong organizational and time management skills.
• Ability to maintain accurate documetnation and follow established workflows.
• Critical thinking and problem-solving abilities.
• Compassionate, patient-centered approach to care.
Physical Requirements:
• Prolonged periods of sitting and computer work.
• Frequent telephone communication.
• Ability to occasionally lift up to 20 pounds.
• In office 2 days per week after training is complete and checked off.
This position plays a vital role in improving patient outcomes by increasing access to preventative services, enhancing disease management, and supporting organizational quality and value-based care goals.
