Chronic Disease Program Assistant

Position Status




NHC Position Type

Patient Navigator

Position Summary

The NHC member will complete day-to-day tasks associated with community based chronic disease self-management programming. They will serve directly with our Program Coordinator to maintain patient referrals, provide health education, information, and resources to the community benefit population served by The Center for Urban Health. The NHC member will conduct evaluations of diabetes and chronic disease programs based on protocols and procedures developed by the Center for Urban Health. These evaluations include data collection through surveys and interviews with program participants, data management and analysis and generating reports.

Major Duties and Responsibilities

  • screening patients for health concerns and eligibility
  • following-up with patients to ensure documentation is completed
  • providing education on how to complete paperwork
  • providing brief health education to patients
  • coordinating with other programs to provide health classes
  • tracking, enrolling, and surveying patients for improvement
  • recruiting clients to participate in health classes
  • co-facilitating group classes on health and lifestyle
  • informal one-on-one training on client referrals
  • attending meetings and patient huddles
  • preparing and reviewing intake checklists/consent forms
  • conducting phone outreach as assigned by leadership
  • assisting in care coordination and resource referrals
  • tracking referrals and closing the referral loop
  • evaluating referral charts and obtaining reports
  • conducting outreach to patients via phone/letters
  • linking patients to care by scheduling appointments
  • researching and designing monthly education displays
  • collaborating with leadership to meet needs of materials
  • interacting with patients to complete quality reviews
  • utilizing survey tools to upload data from interviews
  • conducting extensive and continuous research on social services
  • creating social service resources guides and lists for clients
  • developing various programs on improving health literacy
  • developing assessment tools to track patient improvement
  • coordinating for resource distribution with other programs
  • scheduling and coordinating communication for outreach visits
  • assessing community data to locate areas that would benefit from community health screenings and referrals
  • registering patients as well as providing follow-up social service navigation
  • finding additional community resources and programs for patients

Characteristics of an Ideal Candidate

  • Comfortable with diversity
  • Basic knowledge of medical terminology
  • Proficient computer and data entry skills (e.g., Microsoft Excel)
  • Multi-tasker; ability to balance
  • Self-manager
  • Good communication skills
  • Outgoing
  • Independent
  • Open-minded
  • Non-judgmental
  • Takes initiative
  • Comfortable in fast-paced environment
  • Organized; sound organizational skills
  • Good customer service
  • Good telephone skills
  • Knowledge of health records
  • Flexible
  • Persistent
  • Start projects independently

Knowledge Required for the Position

  • Knowledge of AmeriCorps/Health Corps member requirements
  • Skill with Microsoft Office or other software for a variety of data processing operations involving a range of problem solving, record keeping, correspondence, and service tracking options


  • Member uses initiative in carrying out recurring assignments following set procedures, independently.
  • The supervisor assigns service activities, advises on changes in procedures, and is available for assistance when required.
  • The supervisor assigns service activities in terms of project objectives and basic priorities and is available for consultation in resolving controversial issues.


  • The service activities are reviewed for accuracy through spot checks, through complaints from customers, and through observation of the Member at service.
  • The Member independently plans and carries out the projects and selects the approaches and methods to be used in solving problems.


  • Written and oral guides provide specific instructions for doing service.
  • Detailed guidelines exist, including regulations and directives, handbooks, precedents, industry standards and files of previous projects.
  • Guidelines are generally applicable, but the Member independently makes adaptations in dealing with problems and unusual situations.


  • Member has to develop, analyze, or evaluate information before the service position can progress.

Special Considerations

  • Schedules are flexible and may require evening and weekend programs

Criminal History Check Requirements Beyond NHC Standard Checks

  • Child abuse clearance