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The Population Health Specialist is responsible for outreach to patients with gaps in chronic disease management and preventive care. Requires strong time management and the ability to work independently. Must be able to prioritize multiple assignments based on the need of the organization.
Counties covered: Newport, Oxford, St. Clair Shores, Novi, and portions of Dearborn.
- 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 care improvements.
- Shares findings of identified concerns/issues/quality care improvements related to gap closure, ordering process and documentation of care with quality team so that they may be addressed and/or implemented efficiently and effectively.
- Prepares reports as needed.
- Collaborates with practice staff to provide additional information and coordination of practice level phone calls.
- Performs special focused projects/audits as assigned.
- Complete all scheduled eye exams at ambulatory clinics, updating portal information, and ensure practices receive results for all patients.
- Traveling to ambulatory sites.
- Investigation of community resources/assistance needed for patient population; ensure an agency guest and/or information is available monthly to support the development of the material provided to the clinics.
- Outreach to outside clinics and health systems for results and quality data needed for improvement of practice scores.
- Perform quarterly quality measure audits to ensure practices compliance with documentation requirements.
- Required High School Diploma or equivalent
- EPIC experience preferred
- 2 years of relevant experience Minimum of 2 years of experience as a medical assistant in an outpatient setting or a primary care setting
- Pallet to Waist (6" from floor) > 5 lbs: Seldom up to 25 lbs
- Waist to Waist > 5 lbs: Seldom up to 25 lbs
- Waist to Chest (below shoulder) > 5 lbs: Seldom up to 10 lbs
- Waist to Overhead > 5 lbs: Seldom up to 5 lbs
- Bilateral Carry > 5 lbs: Seldom up to 25 lbs
- Unilateral Carry > 5 lbs: Seldom up to 10 lbs
- Pushing Force > 5 lbs: Seldom up to 20 lbs
- Pulling Force > 5 lbs: Seldom up to 15 lbs
- Sitting: Occasionally
- Standing: Occasionally
- Walking: Occasionally
- Forward Bend - Standing: Seldom
- Forward Bend - Sitting: Seldom
- Trunk Rotation - Standing: Seldom
- Trunk Rotation - Sitting: Seldom
- Squat: Seldom
- Stair Climbing: Seldom
- Crawling / Kneeling: Seldom
- Reach - Above Shoulder: Seldom
- Reach - at Shoulder or Below: Seldom
- Handling: Occasionally
- Forceful Grip > 5 lbs: Seldom
- Forceful Pinch > 2 lbs: Seldom
- Finger/Hand Dexterity: Frequently
- Visual Acuity
[None = No; Seldom = Yes]: Seldom - Color Vision (Ishihara) Test
[None = No; Seldom = Yes]: Seldom
Primary Location
SITE - Beaumont Service Center - 26901 Beaumont BlvdDepartment Name
Accountable Care OrganizationEmployment Type
Full timeShift
Day (United States of America)Weekly Scheduled Hours
40Hours of Work
8 a.m. to 4:30 p.m.Days Worked
Monday to FridayWeekend Frequency
Variable weekendsCURRENT COREWELL HEALTH TEAM MEMBERS - Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only.
Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.
Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.
An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.
You may request assistance in completing the application process by calling 616.486.7447.
Beaumont Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, gender identity, sexual orientation, age, status as a protected veteran, or status as a qualified individual with a disability.