Patient Population Management Specialist

Position Status




NHC Position Type

Patient Navigator

Position Summary

The Patient Population Management Specialist will serve as part of the Care Navigation team, providing patients with increased access to care, case management services, and health education. The NHC member will work directly with new patients at both Squirrel Hill Health Center locations, offering new patient orientation classes. These classes will increase access to care by orienting patients to the services offered at the Health Center, as well as how to access health care services in the community.  There will be a special focus for these orientations to be targeted to newly arriving refugees in order to educate them both about the Squirrel Hill Health Center and the complex American health care system.  Often new refugees are more likely to end up in the costly emergency room setting at local health care systems because they don’t understand the importance of calling their primary care office for help.  With continued education we hope to decrease unnecessary emergency room visits as well as increase our patients’ utilization of our preventative care service offerings. The member will also create health education campaigns addressing the chronic condition and vaccination topics to share with patients on our social media accounts as well as through in-office education boards/areas.

The NHC member will also help with other patient support programs including working directly with groups of patients identified with specific health needs, such as high blood pressure and diabetics with elevated blood glucose, missing vaccines, and overdue PCP appointments. The member will work directly with the patients and SHHC clinical and care navigation staff to track patient needs and coordinate necessary follow up care, such as PCP, lab, and specialist visits.  In addition, the member will assist staff to proactively identify patients that have not followed up on critical preventative care services, such as physicals and immunizations.  The member will work directly with the patients and clinical staff to schedule needed services and coordinate completion with SHHC staff. The member will contact patients using phone calls, letters, and occasional in-person encounters, in order to schedule them for these appointments. Using reports generated from our health records, the member will assist staff to proactively identify patients who have not followed up on these critical preventative care services. As part of the monthly vaccine tracking initiative, the member will assist qualified patients with a vaccine assistance program application. The member will be part of SHHC’s Quality Committee and meet monthly to review key statistics with the committee.

The member will be responsible for tracking assigned patient populations by contacting individuals to schedule appropriate and necessary appointments at SHHC. The member will also coordinate and facilitate patient orientation sessions at both SHHC locations.

The member will be working directly with individual patients (both in-person and by phone) to increase access to primary and preventive healthcare services. The member’s service will directly increase access to care for vulnerable patients. Through patient tracking, the member will work to ensure that older adults and children have appropriate primary care check-ups, and will also work with our substance use disorder patients through other patient tracking initiatives.  By following the children in our practice and ensuring adherence to a well-child visit schedule, the member will assist our clinicians to make sure we have frequent interactions and screenings for childhood obesity and also ensure that we are providing the appropriate counseling on physical activity and nutrition needed at each age.  In addition, the member will focus on diabetic and hypertensive patients, both conditions linked to obesity, and work to ensure these patients are getting appropriate follow-up care to manage these chronic conditions. Through health education campaigns, the member will work on topics addressing all of NHC’s service focus areas.

The member’s service activities will address structural oppression through a focus on outreach to patients to build and strengthen internal systemic changes to link patients back to care and identify common barriers to help restructure workflows to address barriers.

Member’s activities can be completed remotely via teleservice if restrictions remain in place during the service year.

Over half of SHHC’s patients are refugees or immigrants with limited English proficiency and approximately 74% of current patients have low incomes and are either uninsured or Medicaid insured.  In addition, there are several high risk groups that SHHC provides care for, including: uninsured pregnant women, vulnerable older adults, refugees, adults with chronic medical and mental illness, and patients in substance abuse recovery. The member will be working directly with these vulnerable populations daily through both their patient orientation work and population management work.

Major Duties and Responsibilities

  • Tracking, enrolling, and surveying patients for improvement
  • Conducting phone outreach as assigned by leadership
  • Conducting outreach to patients via phone/letters
  • Linking patients to care by scheduling appointments
  • Collaborating with leadership to meet needs of materials

Characteristics of an Ideal Candidate

  • Comfortable with diversity
  • Basic knowledge of medical terminology
  • Proficient computer and data entry skills (e.g. Microsoft Excel)
  • Good communication skills
  • Good telephone skills
  • Knowledge of health records

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.


  • 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.


  • The service position assignments vary significantly or often involve unusual circumstances and incomplete or conflicting data.
  • The Member must develop new techniques, methods, or approaches to complete service position assignments.

Purpose and Impact of Service Position Assignments

  • The service position product or service affects the design or operation of systems, programs, or equipment.
  • The service position product or services affect the social, physical, and economic well-being of a substantial number of people on an ongoing basis.
  • The member is required to investigate or analyze a variety of unusual conditions, problems, or questions.

Nature of Contacts

  • Clients

Purpose of Contacts

  • To provide customer service

Special Considerations

  • Health screening or service required

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.  Along with these checks, ALL NHC Pittsburgh Members Are Required to be Vaccinated against COVID-19. 

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.