What are the responsibilities and job description for the Clinical Outreach Nurse – LPN/RN position at Southwoods Health?
Southwoods Health is currently hiring a Clinical Outreach Nurse. This position focuses on patient engagement, preventive care gap closure, and medication adherence outreach to improve quality outcomes. The role requires strong skills in care coordination, communication, and population health management. The coordinator collaborates with the Quality Department, providers, and managed care organizations to identify high-risk or non-compliant patients, coordinate preventive services, and connect patients with needed resources to support quality initiatives.
Responsibilities
Patient Outreach & Care Coordination:
At Southwoods, it's not just about the treatment, but how you're treated. #SWH
www.southwoodshealth.com
Responsibilities
Patient Outreach & Care Coordination:
- Conduct proactive outreach (phone calls, letters, or portal messages) to high-risk and non-compliant patients to schedule preventive and chronic care visits, review open care gaps, and discuss needed screenings or labs.
- Engage patients in meaningful conversation to identify barriers to care such as transportation, cost, scheduling conflicts, or health literacy, and connect them with appropriate resources or support.
- Collaborate with care teams to drive patient follow-through and care gap closure.
- Review payer dashboards, pharmacy adherence reports, SUPD/SPC metrics, CPC rosters, and internal quality reports to identify priority patients for outreach.
- Track and analyze gap closure progress, medication adherence trends, and outreach effectiveness to support performance goals.
- Share findings, trends, and opportunities for improvement with the Quality Incentive Supervisor to guide workflow adjustments, staff education, and program enhancements.
- Identify and reach out to patients with medication adherence gaps to confirm refill status, review extended-supply or formulary coverage options and assist with home-delivery enrollment.
- Educate patients on the importance of consistent medication use, discussing potential side effects, long-term health impacts, and practical strategies to stay on track, such as setting phone reminders, using pill organizers, or aligning refills with routine appointments.
- Collaborate with pharmacies, providers, and care teams to resolve barriers such as cost, side effects, or refill timing.
- Participate in pharmacy education and training sessions offered by managed care organizations (MCOs) to stay current on adherence strategies and available resources.
- Utilize payer and MCO dashboards and reports to track adherence metrics, document interventions, and monitor improvement over time.
- Document all outreach attempts, patient responses, and next steps using approved systems (Citrix, Power BI, Meditech) to ensure consistent tracking and communication across the care team.
- Maintain confidentiality and adhere to HIPAA guidelines.
- Prior experience in a healthcare or patient outreach setting
- Strong interpersonal and communication skills for patient engagement
- Proficiency with Microsoft Office and data systems (Excel, Power BI, Citrix, Meditech)
- Ability to work independently while collaborating with clinical teams
- Background in population health, care coordination, or quality improvement
- Familiarity with HEDIS measures, CPC requirements, and value-based care programs
- Experience in medication adherence outreach or chronic care management
- Licensed Practical Nurse or Registered Nurse
At Southwoods, it's not just about the treatment, but how you're treated. #SWH
www.southwoodshealth.com