Population Health Navigator

Michigan State University; East Lansing (MI); On-site; USD 60,000 - 90,000; Full time

Job summary

Michigan State University in East Lansing seeks a Population Health Coordinator to advance quality, population health, and value‑based care initiatives in partnership with the MOSAIC CIN, ACO, and Henry Ford Health.

The role collaborates with providers, practice teams, and quality leaders to close care gaps, enhance preventive care, and guide patients through navigation, SDOH screening, and care transitions toward better outcomes and health equity.

Qualifications

• Two to three years of college study in healthcare, science, or business with related ambulatory clinical coursework.
• One to three years of related work experience in healthcare settings, EMR and scheduling systems.
• Experience in data analysis and healthcare quality programs.

Responsibilities

• Identify and address care gaps through patient outreach, chart review, and population health reporting tools.
• Support quality initiatives related to preventive screenings, chronic disease management, immunizations, and Annual Wellness Visits.
• Utilize Epic, registries, dashboards, and performance reports to prioritize outreach and intervention opportunities.
• Assist patients in navigating care across primary care, specialty care, hospital, and community settings.
• Support transitions of care following emergency department visits, hospitalizations, and post-acute care encounters.
• Collaborate with providers, practice staff, care managers, community health workers, and quality teams to improve outcomes and patient engagement.
• Conduct and support Social Determinants of Health (SDOH) screening and connect patients with community resources.
• Educate patients on preventive care, chronic disease management, MyChart utilization, and available support services.
• Support CIN, ACO, PCMH, and value-based care initiatives through data collection, reporting, workflow implementation, and performance improvement activities.
• Provide education and support to clinic teams regarding quality measures, care gap workflows, and population health best practices.

Job description

Michigan State University in East Lansing seeks a Population Health Coordinator to advance quality, population health, and value‑based care initiatives in partnership with the MOSAIC CIN, ACO, and Henry Ford Health.

The role collaborates with providers, practice teams, and quality leaders to close care gaps, enhance preventive care, and guide patients through navigation, SDOH screening, and care transitions toward better outcomes and health equity.