Outreach Specialist

Glbhc•Saginaw, MI

2d•Onsite

About The Position

The Outreach Specialist conducts patient outreach and coordinates care-gap closure in support of GLBHC’s strategic plan and value-based contract requirements. Under the direction of the Quality Manager, the role uses payer rosters, ACO attribution lists, internal audits, utilization reports, and organizational priorities to target outreach. Focus areas may include preventive screenings, chronic disease management, Medicare Annual Wellness Visits, immunizations, child and adult wellness visits, and other quality initiatives. The specialist initiates authorized orders, referrals, and documentation workflows in accordance with HEDIS, CMS, and payer-specific guidelines, and coordinates multiple services within a visit when possible. The role serves as a patient contact throughout outreach, providing education, scheduling appointments, answering questions, facilitating follow-up, and connecting patients to internal resources and community support. It also conducts pre-visit planning, completes screenings and assessments, requests and reconciles external records, and documents care-gap closure in the EHR and applicable payer or ACO portals. Documentation must meet compliance standards, support audit readiness, and enable accurate quality reporting. The position is full-time with flexible and varied hours; evening hours may be required. Hybrid or telecommuting work is not available. Limited local travel between GLBHC sites may be required, with personal-vehicle use reimbursed according to corporate policy when required. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

Requirements

High school diploma required.
Excellent telephone etiquette.
Computer skills, including word processing, Excel, and electronic health records.
Ability to operate office equipment, including a computer, fax machine, and copy machine.
Ability to follow through with assignments responsibly, accurately, and efficiently.
Ability to communicate effectively with and relate professionally and courteously to a diverse population.
Ability to follow oral and/or written instructions.
Ability to work independently and as a team member.
Must be able to sit, stand, and/or walk for an entire workday.
Must be able to lift, carry, push, pull, and/or twist while holding up to 25 pounds occasionally.

Nice To Haves

Certification as a Medical Assistant preferred; Licensed Practical Nurse (LPN) and/or Certified Nursing Assistant credentials will be considered.
At least one year of experience in a medical setting preferred.
Knowledge of insurance plans is helpful.

Responsibilities

Conduct targeted patient outreach using payer rosters, ACO attribution lists, internal audits, utilization reports, and site or organizational priorities.
Prioritize outreach under the direction of the Quality Manager in alignment with GLBHC’s strategic plan and value-based contract requirements.
Support preventive screenings, chronic disease management, Medicare Annual Wellness Visits, immunizations, child and adult wellness visits, and other quality projects and measures.
Initiate authorized orders, referrals, and documentation workflows to close care gaps in accordance with HEDIS, CMS, and payer-specific guidelines.
Coordinate multiple services within a single visit when possible to reduce patient burden and improve completion rates.
Support ACO quality and utilization initiatives, including attribution maintenance and measure-performance improvement projects.
Serve as a consistent point of contact for patients throughout outreach and gap closure.
Schedule wellness visits and follow-up appointments, remind patients of upcoming services, and update patient charts accurately and promptly.
Explain the purpose of outreach, recommended services, and next steps; respond to patient questions and concerns; and facilitate follow-up calls.
Connect patients with appropriate internal resources, including clinical staff, Behavioral Health, Referrals, and Community Health Workers through warm handoffs.
Build collaborative relationships with providers, care teams, Community Health Workers, and site staff to support continuity and patient-centered care.
Conduct pre-visit planning for patients scheduled within timeframes determined by the Quality Manager.
Complete and document required screenings and assessments.
Request external records, reconcile documentation, and close care gaps in the EHR and applicable payer or ACO portals within required timeframes and compliance standards.
Ensure documentation supports audit readiness and accurate quality reporting.
Conduct outreach to patients assigned by health plans, ACOs, or other value-based entities to establish or re-establish care at GLBHC.
Schedule appointments, provide pre-visit support, and document outreach attempts according to payer and organizational requirements.
Remove patients from active outreach after three unsuccessful contact attempts or confirmation that they receive care outside GLBHC.
Schedule transportation or contact ancillary staff to assist with patient needs.
Perform other duties as assigned.