Clinical Solutions Specialist - General Medicine

About the role

The Clinical Solution Specialist is responsible for the design, implementation, and evaluation of clinical care solutions that improve patient outcomes, support value-based care initiatives, and align with organizational goals. This role serves as a subject matter expert bridging clinical expertise and operational strategy, working closely with cross-functional teams including clinical operations, quality, technology, and business development.

Responsibilities

• Bridges clinical expertise and operational strategy by working closely with cross-functional teams including clinical operations, quality, technology, and business development.
• Brings deep knowledge of adult care delivery models and leverages data to inform the creation of scalable, patient-centered solutions across care settings.
• Develops workflows that support provider practice operations, nursing-led chronic condition care planning, patient assessments, care coordination, medication and adherence support, and escalation pathways for acute or emerging patient needs.
• Develops quality improvement strategies, patient care models, health risk mitigation approaches, and cross-functional workflows that are clinically sound, operationally feasible, and aligned to adult population needs.
• Engages patients during admission and discharge, completes discharge assessments, coordinates timely provider follow-up, supports nursing-led transition planning, and helps care teams reduce avoidable emergency department visits, hospitalizations, and readmissions.

Requirements

• Nursing degree (BSN or higher preferred); RN license required
• Minimum 3 years of experience in clinical care delivery, care management, or clinical program design. Experience in value-based care or population health strongly preferred
• Project Management certification, lean six sigma, and/or other related certifications preferred
• Proficiency in project management tools and methodology
• Prior experience building adult care solutions and workflows
• Strong understanding of care delivery across diverse populations and settings (e.g., ambulatory, post-acute, home health, etc.)
• Familiarity with social determinants of health and how they impact patient care delivery
• Experience developing workflows and care models with clinical and non-clinical teams
• Proficiency in Electronic Medical Record (EMR) software and workflow documentation
• Clinical education and training experience (especially for nurses and care teams)
• Understanding of Medicare and Medicaid reimbursement structures
• Competent in Microsoft Office Suite and Visio for process design

Key Behaviors

• Collaboration & Teamwork: Collaborates with internal stakeholders to ensure solutions are clinically sound and operationally viable. Actively listens to team members and stakeholders and integrates their feedback into Solution development.
• Problem Solving & Decision Making: Uses data analysis and clinical insights to inform decisions and develop effective solutions for improving Solution outcomes. Demonstrates the ability to identify issues, assess risks, and implement corrective actions.
• Communication & Influence: Communicates complex clinical concepts clearly to both internal and external stakeholders. Influences care teams by presenting evidence-based rationales for workflow designs and updates. Demonstrates active listening and empathy, particularly in engaging with patients or healthcare professionals regarding behavioral health and substance use issues. Effectively presents training materials and Solution updates to a variety of audiences, including patients, providers, and interdisciplinary teams.
• Adaptability & Flexibility: Adapts to changes in clinical solution needs, evolving best practices, regulatory or contractual requirements, or stakeholder expectations. Willingness to adjust to changing schedules and demands, including the flexibility to work occasional nights and weekends.
• Attention to Detail: Reviews medical records and clinical data with high attention to accuracy and compliance with regulations and standards (e.g., HEDIS measures, HIPAA). Ensures thorough documentation and synthesis of patient and solution data for reporting.
• Leadership & Accountability: Takes ownership of the development and ongoing refinement of clinical solutions. Responsible for meeting quality improvement metrics and patient outcomes associated with their solutions. Demonstrates leadership in clinical Solution training, ensuring all involved parties are educated on key aspects of the solution.
• Patient-Centered Care: Prioritizes patient-centered care in the design of clinical solutions. Ensures that patient feedback and real-life outcomes are incorporated into the clinical solution’s evolution.
• Efficiency & Time Management: Manages competing priorities and multiple stakeholder demands, ensuring deadlines are met and outcomes are achieved efficiently. Organizes workflows and schedules for solution implementation, training, and assessment in an effective manner.
• Training & Education: Assesses learning needs and collaborates effectively with clinical education team to build customized training solutions to diverse audiences. Creates SOPs, job aids, and other materials to support the learning of care team members and at times, may participate in training.

Competencies

• Clinical Solution Development: Lead the design and development of clinical solutions and care models that address patient needs across the care continuum. Translate clinical insights, evidence-based practices, and patient outcomes into actionable workflows and solution strategies. Expertise in designing pediatric and transitions of care workflows with a focus on reducing readmissions, enhancing care continuity, and improving family engagement. Ability to analyze patient data to identify opportunities for solution enhancements.
• Primary Care & Chronic Disease Management Knowledge: Detailed understanding of Provider/patient experience building and effective visit methods. Knowledge of problem identification and diagnosis code capture. Strong understanding of clinical care team collaboration to effectively provide whole-person care. Knowledge of chronic disease management techniques for nursing care planning and appropriate ties to the Provider’s plan of treatment. Develop and implemented standardized workflows for developing primary and specialty care directories for more efficient patient resource support and navigation.
• Clinical Triage Knowledge: Knowledge of clinical triage principles to support timely assessment, prioritization, escalation, and resolution of acute patient needs. Understanding of nurse-led triage workflows, including symptom assessment, clinical decision support, provider escalation, and patient follow-up. Knowledge of transitions of care and readmission avoidance processes, including discharge follow-up, care coordination, medication-related concerns, and escalation of post-discharge risks.
• Healthcare Process Design & Workflow Engineering: Supports the mapping, standardization, and improvement of clinical workflows across provider practices, triage pathways, chronic condition care planning, and transitions of care. Develops workflows that reduce unnecessary variation, handoffs, and bottlenecks while supporting appropriate clinical judgment, efficiency, and patient safety. Identifies process gaps and recommends workflow improvements to support reliability, quality, and patient outcomes. Contributes to workflow designs that can be adapted across markets, technologies, and care delivery environments.
• Project Management: Familiar with project management tools and methodologies to plan, execute, and monitor the progress of clinical solution initiatives. Experience in coordinating timelines, resources, and stakeholder engagement to ensure the successful rollout of solutions.
• Data Analysis & Reporting: Skilled in collecting, analyzing, and synthesizing clinical data, including health outcomes, patient satisfaction, and quality metrics. Proficient in creating actionable reports and presenting findings to leadership.
• Change Enablement & Organizational Readiness: Designs clinical solutions with consideration for how providers and care teams will adopt and sustain workflow changes. Identifies potential adoption risks and incorporates practical considerations into workflow and solution design. Partners with operational and clinical leaders to support solutions that are executable and sustainable in real-world care settings. Supports change efforts by helping care teams understand workflow updates, implementation expectations, and transition needs.
• Regulatory Compliance & Accreditation: Proficiency in adult care and transition-related regulatory guidelines and quality standards (e.g., HEDIS, NCQA). Ensures audit readiness and documentation compliance across solutions.
• Technology Proficiency: Competence with Electronic Medical Records (EMR) systems and familiarity with healthcare-related software to enhance Solution delivery and data tracking. Ability to utilize technology to improve solution outcomes and operational efficiency. Ability to write in problem statement format to improve solutioning.

Upward Health Benefits

Upward Health offers a comprehensive benefits package designed to support the health and well-being of our employees. This includes:

• Health Insurance
• Retirement Savings Plans
• Flexible Spending Accounts
• Employee Assistance Programs
• Wellness Programs
• Professional Development Opportunities

Upward Health Core Values

At Upward Health, we believe in fostering a culture that values diversity, equity, and inclusion. Our core values guide us in creating a workplace where everyone feels valued and empowered to contribute their unique perspectives and talents. These values include:

• Inclusivity
• Diversity
• Ethics
• Integrity
• Empowerment
• Accountability

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