Corewell Health·Southfield, Michigan
Conduct targeted outreach to patients with gaps in chronic disease management and preventive care to improve health outcomes. Coordinate access to services, maintain tracking of gap closures, and collaborate with care teams to implement quality improvements.
Make a meaningful impact on the health and well-being of your community as a Patient Outreach Specialist!
In this highly visible role, you’ll connect with patients across multiple communities, helping them stay on track with preventive care and chronic disease management.
By building trusted relationships, coordinating access to important healthcare services, and partnering closely with providers and care teams, you'll play a vital role in improving health outcomes and closing gaps in care.
If you are passionate about patient engagement, enjoy collaborating with others, and thrive in a mission-driven environment where every interaction can make a difference, we encourage you to apply and join our team.
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 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 Minimum of 2 years of experience as a medical assistant in a physician clinical practice, a clinical nursing program, or in a population health related role. Preferred EPIC experience Completion of an accredited Medical Assistant program or LPN, EMT, ER Tech, or equivalent of education and relevant experience. About Corewell Health As a team member at Corewell Health, you will play an essential role in delivering personalized health care to our patients, members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement - to improve health, instill humanity and inspire hope. Join a nationally recognized health system with an ambitious vision of continued advancement and excellence. #CorewellHealthCareers
Requires a high school diploma and at least 2 years of experience as a medical assistant or in a population health role. Experience with EPIC and completion of an accredited Medical Assistant program or LPN/EMT certification is preferred.
Market context
In Michigan, Outreach Specialist roles are often tied to public health, HIV prevention, and community-based service delivery, so demand tends to follow programs that need direct client engagement and care navigation. These positions are competitive because employers usually look for candidates with lived or service-related HIV prevention experience, plus a high school diploma or GED and, when preferred, a Community Health Worker certification. Review the AI-summarized requirements and benefits carefully on this platform to save research time, then tailor your application to show outreach, trust-building, and referral experience.
