Chronic Disease Program Assistant

Position Status




NHC Position Type

Patient Navigator

Position Summary

The NHC member will be responsible for the day-to-day tasks associated with community based chronic disease self-management programming (hypertension, diabetes, stroke, etc.). They will serve directly with our team to maintain patient referrals, provide health education, information, and resources to the community benefit population served by Philadelphia Collaborative for Health Equity (Collaborative).   The NHC member will participate in chronic disease self-management programs based on protocols and procedures developed by the Collaborative / Frazier Family Coalition. Tasks 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
  • 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
  • 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
  • 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
  • Developing assessment tools to track patient improvement
  • Ensuring inventory is stocked and stored appropriately
  • 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-judgemental
  • Takes initiative
  • Comfortable in fast-paced environment
  • Organized; sound organizational skills
  • Good customer service
  • Good telephone skills
  • 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


  • The supervisor assigns service activities in terms of project objectives and basic priorities and is available for consultation in resolving controversial issues.


  • Completed projects are reviewed very generally to determine that objectives have been met and are in compliance with policies and regulations.


  • Guidelines are generally applicable, but the Member independently makes adaptations in dealing with problems and unusual situations.
  • Member must use considerable judgment in adapting current or developing new guidance.
  • Ongoing training and support is available for the member


  • Member has to develop, analyze, or evaluate information before the service position can progress.
  • The Member must develop new techniques, methods, or approaches to complete service position assignments.
  • Responsibilities and task can vary frequently depending on the specific needs of the organization at that time.

Purpose and Impact of Service Position Assignments

  • Member provides timely services of a personal nature to others.
  • The service position product or service affects the accuracy, reliability, or acceptability of further processes or services.
  • The service position product or services affect the social, physical, and economic well-being of a substantial number of people on an ongoing basis.

Nature of Contacts

  • Clients
  • The service member frequently interacts with community members and participants.

Purpose of Contacts

  • To motivate, influence, or educate people to support change behaviors.

Special Considerations

  • Unusual service hours, involving evenings, weekends, or long shifts
  • The member may need to attend events on the weekends or teach classes in the evenings.
  • Proof of COVID-19 vaccination required upon hire.