Patient Outreach Specialist
Corewell Health · Southfield, Michigan, US
Job Summary The Population Health Specialist is responsible for outreach to patients with gaps in chronic disease management and preventive care.
Job description
Job Summary The Population Health Specialist is responsible for outreach to patients with gaps in chronic disease management and preventive care. This role serves to support health status improvement through access to services, education, wellness support and reinforcing the importance of the patient/primary care provider relationship. Counties covered: Newport, Oxford, St. Clair Shores, Novi, and portions of Dearborn. Essential Functions: - Utilizes the Medical Home model to provide targeted outreach to identified patients. Includes current and new patients. - Working on site in up to 15 clinics, in the surrounding area. - Utilizes EMR Systems, registries, health maintenance data, opportunity reports, payer portals and other data as available to validate gaps and conduct outreach activities as assigned. - Maintains tracking of outreach and gap closure. - Using EMR tools, initiates outreach via EMR portal messages, phone calls, and/or via letters. - Updates EMR Systems and payer portals as appropriate. - Supports supplemental data submission process for plans without electronic supplemental feeds. - Collaborates with Practice Transformation Team on the identification of quality car...