Outreach Specialist

Great-Lakes-Bay-Health-Centers; Saginaw (MI); On-site; USD 42,000 - 54,000; Full time

Job summary

Great Lakes Bay Health Centers is seeking a full-time, on-site Medical Assistant focused on patient outreach and closing care gaps within value-based care initiatives.

You will conduct targeted outreach, schedule wellness visits, and coordinate with care teams. A high school diploma and MA certification are preferred; 1 year medical experience is preferred. Hybrid/telecommuting is not available.

Qualifications

• Education: High school diploma required.
• Certification as Medical Assistant preferred; LPN or CNA will be considered.
• Minimum of one year experience in a medical setting preferred.
• Excellent telephone etiquette and computer skills with EHR experience.
• Knowledge of insurance plans helpful.

Responsibilities

• Conduct targeted outreach based on payer rosters, ACO attribution lists, audits and reports; align with strategic priorities.
• Initiate orders, referrals, and documentation workflows to close care gaps per guidelines; coordinate multiple services in a visit.
• Schedule wellness visits and follow-up appointments; educate patients on outreach purpose and next steps.
• Respond to patient questions; facilitate follow-ups and connect patients with internal resources.
• Close care gaps in EHRs and payer portals; support audit readiness and quality reporting.

Skills

Telephone etiquette

Computer skills

Microsoft Word

Excel

EHR

Education

High school diploma

Medical Assistant certification preferred

LPN or CNA considered

Job description

• On-site
• Medical Assisting
• Full-Time
• Requisition #: OUTRE002673

Description

ESSENTIAL JOB DUTIES

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Patient Outreach & Gap Closure (50%)
  • Conduct targeted outreach based on payer rosters, ACO attribution lists, internal audits, utilization reports, and site or organizational priorities. Under the direction of the Quality Manager, prioritize outreach aligned with GLBHC’s strategic plan and value‑based contract requirements. Focus areas may include preventive screenings, chronic disease management, Medicare Annual Wellness Visits, immunizations, child and adult wellness visits, special projects, assisting with tracking outcomes and other quality 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‑specific quality and utilization initiatives, including attribution maintenance and measure performance improvement projects. Assist with additional value‑based care projects as assigned.
• Serve as a consistent and trusted point of contact for patients throughout the outreach and gap‑closure process. Schedule wellness visits and follow‑up appointments, remind patients of upcoming services, and update patient charts accurately and timely. Provide clear education on the purpose of outreach, recommended services, and next steps.
• Respond to patient questions and concerns, facilitate follow‑up calls, and connect patients with appropriate internal resources, including clinical staff, Behavioral Health, Referrals, and warm handoffs to Community Health Workers. Build collaborative relationships with providers, care teams, CHWs, and site staff to ensure continuity, clarity, and patient‑centered care.
• Gap Closure Documentation (20%)
  • Conduct Pre‑Visit Planning (PVP) for patients scheduled within designated timeframes as determined by the Quality Manager. Complete and document required screenings and assessments.
  • Request external records, reconcile documentation, and close care gaps within the EHR and applicable payer or ACO portals in accordance with compliance standards and required timeframes. Ensure documentation supports audit readiness and accurate quality reporting.
• Payor-Assigned Patient Outreach (10% )
  • 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 of care outside GLBHC.

MARGINAL JOB DUTIES

• Scheduling transportation and/or reaching out to other ancillary staff to assist patient needs.
• Performs other duties as assigned.

REQUIRED JOB SPECIFICATIONS

• Education: High school diploma required
• Licensure: Certification as a Medical Assistant preferred. Licensed Practical Nurse (LPN) and or Certified Nursing Assistant will be considered.
• Experience: Minimum of one year experience in a medical setting preferred
• Skills: Excellent telephone etiquette. Computer use; including word processing, excel, and Electronic Health Records. Able to operate office equipment including computer, fax machine, copy machine, etc. Able to follow through with assignments responsibly, accurately and efficiently.
• Interpersonal Skills: Ability to communicate effectively with, and relate to a diverse population in a professional and courteous manner. Ability to follow oral and/or written instructions. Knowledge of insurance plans helpful. Able to work independently and as a team member.
• Physical Effort: 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 lbs. occasionally.
• Hours: Full time, flexible and varied. Evening hours may be required. Hybrid/telecommuting is not an available option for this role.
• Travel: Local travel between GLBHC sites may be required on a limited basis. If usage of a personal vehicle is required, reimbursement will be made in accordance with corporate policy.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin.

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.