Outreach Specialist, ACCESS

As an Outreach Specialist on the ACCESS Team, you will play a vital, frontline role in driving patient participation, enrollment, and activation for the Aledade Access Program. Supporting the CMS Innovation Center’s ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) model, Aledade is building an agentic AI patient engagement platform designed to detect, manage, and empower patients with cardio-kidney-metabolic (CKM) disease, in close partnership with primary care practices.

Operating in a dynamic, remote environment, you will serve as the crucial human connection when automated workflows require hands-on support. In this role, you will handle daily multimodal patient outreach, guide device onboarding, and manage operational queues to ensure seamless, patient-centered care. By bridging gaps when automated systems require intervention, assisting patients with technical and clinical tasks, and coordinating rapid triage, you will help uphold exceptional service standards within a high-accountability, innovative care model.

Primary Duties

Patient Outreach & Engagement

• Conduct outbound and inbound outreach calls when automated workflows fail or require manual intervention.

• Assist patients with onboarding, clinical metric collection (e.g., height, weight, BP), and blood pressure monitor troubleshooting.

• Deliver engagement nudges to prompt completion of outstanding care management tasks and support ongoing care continuity.

• Manage high-volume inbound queue requests, SMS fallout, patient inquiries, and onboarding/enrollment support.

• Process webform exceptions and execute timely clinical triage handoffs to RNs and Pharmacists as needed.

• Meet core operational benchmarks for call volume, contact rates, conversion, and device onboarding while maintaining accurate documentation and HIPAA compliance.

• Provide timely, clear, and professional communication regarding follow-ups, care plans, and practice policies.

Operational Support

• Accurately document all patient interactions and maintain up-to-date records in care systems (EHRs/CRMs).

• Track and report patient engagement metrics, participating in workflow testing to refine operations and identify improvements.

• Respond promptly to time-sensitive updates, adjusting priorities to address critical outreach needs immediately.

• Maintain high energy, professional empathy, and resilience during high-volume shifts and frequent patient rejections.

• Collaborate cross-functionally to advance patient engagement strategies and organizational goals.

Minimum Qualifications

• High school diploma or equivalent 

• Minimum of 2 years of experience in healthcare outreach, care coordination, or telephonic patient engagement.

• Proven track record in high-volume environment with the ability to meet performance metrics (i.e. Activation, conversion, etc.).

• Regular and predictable attendance

• Excellent interpersonal, verbal, and written communication skills.

• Strong organizational and documentation abilities.

• Detail-oriented with the ability to manage multiple priorities efficiently.

• Ability to work shifts between 8:00 AM – 8:00 PM EST, including evenings and Saturdays as needed.

Preferred Qualifications

• Experience in a remote call center environment.

• Familiarity with value-based care models and Medicare Advantage.

• Experience with care management software and Electronic Health Record (EHR) systems.

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.