Outreach Specialist

Great Lakes Bay Health Centers•Saginaw, MI

8d•Onsite

About The Position

The Outreach Specialist conducts patient outreach and supports care-gap closure in alignment with 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 focus on preventive screenings, chronic disease management, Medicare Annual Wellness Visits, immunizations, wellness visits, special projects, and other quality measures. The specialist initiates authorized orders, referrals, and documentation workflows in accordance with HEDIS, CMS, and payer-specific guidelines, and supports ACO quality, utilization, attribution, and performance-improvement initiatives. The specialist serves as a patient contact throughout outreach and care-gap closure, scheduling wellness and follow-up appointments, reminding patients about services, updating charts, explaining recommended care and next steps, answering questions, and connecting patients with clinical and other internal resources. The role also builds working relationships with providers, care teams, Community Health Workers, and site staff. The position includes pre-visit planning; completing and documenting required screenings and assessments; requesting external records; reconciling documentation; and closing care gaps in the EHR and applicable payer or ACO portals. Documentation must meet compliance standards and support audit readiness and accurate quality reporting. The specialist also contacts patients assigned by health plans, ACOs, and other value-based entities to establish or re-establish care at GLBHC, documents outreach attempts, and removes patients from active outreach after three unsuccessful contact attempts or confirmation of care outside GLBHC. This is a full-time role 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. The role may also involve arranging transportation or contacting ancillary staff to support patient needs.

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 on 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.
Able to sit, stand, and/or walk for an entire workday.
Able to lift, carry, push, pull, and/or twist while holding up to 25 pounds occasionally.

Nice To Haves

Medical Assistant certification preferred; Licensed Practical Nurse 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 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, special projects, and other quality measures.
Initiate authorized orders, referrals, and documentation workflows to close care gaps under HEDIS, CMS, and payer-specific guidelines.
Coordinate multiple services within a visit when possible to reduce patient burden and improve completion rates.
Support ACO quality and utilization initiatives, attribution maintenance, measure-performance improvement projects, and other assigned value-based care projects.
Serve as a consistent patient contact throughout outreach and care-gap closure.
Schedule wellness and follow-up appointments, remind patients about upcoming services, and update patient charts accurately and promptly.
Educate patients about the purpose of outreach, recommended services, and next steps; respond to 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 set by the Quality Manager, and 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.
Maintain documentation that 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 and/or contact ancillary staff to assist with patient needs.
Perform other duties as assigned.