Patient Population Management Specialist

Position Status




NHC Position Type

Care Coordinator

Position Summary

This member will track patients with chronic disease conditions, as well as patients who have missed critical preventative appointments, and follow-up with these individuals to connect them to primary and preventive healthcare services.  The member will also work on related health education topics to reach patients through social media and in-office educational posters. This member will also provide patient orientation sessions for new patients to orient patients to the services offered at the Health Center, as well as how to access health care services in the community. 

Major Duties and Responsibilities

  • Practicing intake and referrals of patients in need, identifying patients who are at-risk to assess eligibility for various services
  • Offering and reviewing screenings or self-referrals, referring patients to other programs and community services
  • Tracking patients to confirm program enrollment and engagement
  • Providing follow-up and case management to deliver assistance and information
  • Implementing patient engagement strategies to improve outcomes
  • Maintaining professional boundaries and respectinG patient confidentiality
  • Educating patients on medical interventions and prevention
  • Documenting interactions with patients in an electronic health record
  • Attending and participating in community or host site events
  • Creating social media content to promote the programs, collaborating with supervisors and other leadership, providing social service navigation
  • Maintaining, assembling, and distributing materials and supplies
  • Participating in meetings and conferences

In the space below, list other major duties. (Note: major duties represent at least 10% of the time on service.): Member will also meet with new patients to introduce to the services of the health center

Characteristics of an Ideal Candidate

  • Organized; sound organizational skills,
  • Detail-oriented,
  • Comfortable speaking with patient populations, individually or in groups
  • Interested in health and wellness promotion,
  • Experience interacting with patient populations,
  • Team-oriented,
  • Customer-oriented,
  • Positive attitude,
  • Patient and calm,
  • Good verbal and written communication skills,
  • Experience working with patient populations,
  • Creative problem solving,
  • Persistence,
  • Resilience,
  • Open-minded,
  • Non-judgmental,
  • Kind and friendly

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

In the space below, provide additional information or explanations: Member will also be trained on NextGen electronic health record, including tools used for tracking reports


  • 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.

In the space below, provide additional information or explanations.: Member will also work closely with CMO and COO to identify groups for tracking outreach. Member will also be member of quality committee and will present experiences throughout the year to help identify changes to processes/procedures that could benefit patients who may be lost to follow-up


Completed projects are reviewed very generally to determine that objectives have been met and are in compliance with policies and regulations. In the space below, provide additional information or explanations: Member will independently run reports and provide outreach to individual patients. Member will work with CMO to identify health education topics for both social media and in-office education


  • Written and oral guides provide specific instructions for doing service.
  • Guidelines are generally applicable, but the Member independently makes adaptations in dealing with problems and unusual situations.

In the space below, provide additional information or explanations: Member will work within general guidelines for scheduling, but will also work alone and make decisions based on patient needs as well


  • The service position assignments vary significantly or often involve unusual circumstances and incomplete or conflicting data.
  • In making decisions, the Member is often required to depart from past approaches and to extend traditional techniques.
  • The Member must develop new techniques, methods, or approaches to complete service position assignments.

In the space below, provide additional information or explanations.: In working one-on-one with patients who may be lost to follow-up, member will encounter many situations that require decision making within that individual encounter that may not fit written rules. Member will have access to supervisor as well as other staff (from desk, nurses, providers, etc) who can help problem solve complex issues

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.

In the space below, provide additional information or explanations: Member will provide a bridge to patients who are currently lost to care. Through his service member will provide patients with increased access to care to help break down current barriers patients are facing in accessing care

Nature of Contacts


In the space below, provide additional information or explanations: Member will work primarily one-on-one with patients

Purpose of Contacts

To give or exchange information,

In the space below, provide additional information or explanations: Member will help connect patients to health education and appointments

Special Considerations

Unusual service hours, involving evenings, weekends, or long shifts In the space below, provide additional information or explanations: No special considerations required for position. Option available for evening/weekend hours if needed

Criminal History Check Requirements Beyond NHC Standard Checks

In addition to NHC Standard Checks, all NHC Pittsburgh members are required to complete and pass criminal history checks for Great Lakes Behavioral Research Institute/Diversified Care Management (DCM). Great Lakes/DCM is a third party vendor contracted with the Allegheny County Health Department (operating site for NHC Pittsburgh) to distribute NHC Pittsburgh member stipends. NHC Pittsburgh members are onboarded to Great Lakes/DCM system only when the checks have been completed and the member has passed those checks. 

The checks that all NHC Pittsburgh members would be required to complete and pass for Great Lakes/DCM are the following: 1) Act 33 (Pennsylvania Child Abuse Clearance), 2) National Sex Offender Registry Clearance,  3) Act 34 (Pennsylvania Criminal History Clearance, and 4) Act 73 (FBI Criminal History Clearance - ONLY completed via Identogo PA).

NHC members do not have to pay for the completion of these checks. Great Lakes/DCM will distribute payment codes for the Act 33 (Pennsylvania Child Abuse Clearance) and Act 73 (FBI Criminal History Clearance which is conducted through Identogo PA ( PA FBI fingerprinting agency). The National Sex Offender Registry Clearance and Act 34 (Pennsylvania Criminal History Clearance) will be completed by Great Lakes/DCM upon receiving requested information that members will be asked to submit.