What are the responsibilities and job description for the Population Health Coordinator- Full Time position at Full Time - Henry Ford Health - Careers Careers?
GENERAL SUMMARY
Schedule: Full Time, Monday-Friday
Location: Detroit, MI-hybrid position with meetings in offices around Detroit
Position Summary
The Care Coordination & Quality Specialist plays a key role in improving patient outcomes by identifying and addressing gaps in care for patients attributed to a primary care practice. This position works collaboratively with providers, care teams, and patients to support preventive care, chronic disease management, quality performance initiatives, and Patient-Centered Medical Home (PCMH) standards. The ideal candidate is highly organized, detail-oriented, and skilled in using healthcare technology and Microsoft Office applications to drive quality improvement and practice transformation efforts.
Key Responsibilities
- Identify and monitor patient care needs and gaps in care using health plan reports, state immunization registries, electronic medical records (EMR), and disease management registries.
- Collaborate with providers and clinical staff to review, validate, and prioritize identified care gaps based on clinical documentation and patient history.
- Conduct proactive outreach to patients by phone, electronic communication, or other approved methods to facilitate completion of recommended preventive, chronic care, and wellness services.
- Coordinate care activities and connect patients with appropriate resources to ensure timely closure of identified care gaps.
- Support quality improvement initiatives by tracking performance metrics and contributing to strategies that improve clinical outcomes and patient engagement.
- Promote and support high-reliability practices and quality outcomes within the Patient-Centered Medical Home (PCMH) model.
- Utilize Microsoft Office applications and healthcare information systems to analyze data, maintain accurate records, generate reports, and monitor quality measures.
- Participate in practice improvement and transformation activities designed to enhance patient care, operational efficiency, and value-based care performance.
- Maintain compliance with organizational policies, regulatory requirements, and quality program standards.
CERTIFICATIONS/LICENSURES REQUIRED:
- Current BLS-C upon hire or successful completion by end of orientation
EDUCATION/EXPERIENCE REQUIRED:
- High school diploma or G.E.D. equivalent
- Population health experience preferred
- Ambulatory practice support, HEDIS/gap closure, and EHR documentation workflow experience preferred
- Microsoft 365 experience needed