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CommonSpirit Health Population Health Outreach Specialist (CMA or LPN) in CLIVE, Iowa


MercyOne is a connected system of health care facilities and services dedicated to helping individuals live their best life.

With 420 care locations, our clinics, medical centers and affiliates are never too far from home, allowing us to improve the lives of individuals and communities across the state of Iowa and beyond.


Job Summary:

The Population Health Outreach Specialist works as an integral part of an interdisciplinary team to proactively identify patients due or over-due for specific health services. The Outreach Specialist contacts patients, motivates patients to complete recommended health care services and assists in scheduling appointments. The Outreach Specialist supports Population Health patients by closing gaps in recommended clinical care, performing chart reviews, and managing the disease registry.

Essential Position Expectations:

  • Utilizes standardized tools and scripting to conduct patient outreach to patients toschedule and coordinate preventative health care services such as AnnualWellness Visits, cancer screenings, immunizations, and chronic diseaseinterventions.

  • Conducts pre-visit chart review focusing on closing gaps in care and complete,accurate risk coding.

  • Manages CMS web interface quality reporting annually. Supports additionalquality reporting requirements of PHSO contracts as needed.

  • Conducts outreach to patients with medication adherence deficits utilizing thePHSO’s standard medication adherence patient assessment.

  • Identifies and refers high risk patients to the PHSO ambulatory caremanagement team for care coordination services.

  • Practices motivational interviewing to support health behavior change.

  • Requests documents from outside facilities needed to support care gap closures.

  • Oversees the PHSO’s disease registry assuring the database is up to date,accurate and conducting manual data entry when required.

  • Accepts referrals from care management team members to assist with the aboveposition expectations.

  • Answers patient questions regarding appointments and/or testing. Addressespotential barriers to care and collaborates with Provider to answer patientquestions and concerns that fall outside of scope.

  • Documents all patient interactions in the patient’s health record or caremanagement documentation system immediately after the call or meeting iscompleted. The maximum allowable time from interaction to documentation isone business day.

  • Supports and participates in PHSO quality improvement activities at the directionof the quality manager.




Knowledge & Skills:

  • Ability to deal with confidential and sensitive information, requiring ongoing discretion and management of secure information.

  • Strong communication (verbal/written) and organizational skills and ability to interact effectively with providers, clinic staff, and care management team members across the care continuum.

  • Demonstrated capacity to problem solve and prioritize in complex situations.

  • Adaptability to performing a variety of duties, often changing from one task to another of a different nature without loss of efficiency or composure.

  • Ability to function effectively in a team based environment.

  • Basic Excel and Word skills.

  • Ability to understand and apply guidelines, policies and procedures.

  • Obtain Certificate of Competency in Population Health Care Management within 12 months of hire.

  • Proof of completion of Mandatory Reporter within three months of hire.


Associates degree preferred.


Minimum of 3 years health care experience. Varied clinical experience preferred.

Certifications & Licenses:

Iowa state licensure as a Licensed Practical Nurse (LPN) or Certified Medical Assistant (CMA). Basic Life Support (BLS) required.

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Requisition ID 2021-166228

Employment Type Full Time

Department Case Management - Population Health

Hours / Pay Period 80

Shift Day

Standard Hours Monday - Friday (8:00 AM - 5:00 PM)

Facility / Process Level : Name MercyOne Des Moines Medical Center

Location IA-CLIVE

Equal Opportunity CommonSpirit Health™ is an Equal Opportunity/ Affirmative Action employer committed to a diverse and inclusive workforce. All qualified applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, marital status, parental status, ancestry, veteran status, genetic information, or any other characteristic protected by law.