Patient Population Management Specialist

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 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.

• 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
• Researching and designing monthly education displays

• Familiar with health equity-related issues
• Organized
• Detail-oriented
• Comfort speaking with others, individually or in groups
• Compassionate
• An ideal SHHC NHC member will be a highly motivated individual who takes initiative and works well independently. Flexibility is a must. Member must be patient and a sense of humor is helpful to deal with the occasional challenges of working in shared workspace. A passion for working with underserved patients from a variety of cultural backgrounds is also an absolute requirement.

• 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 will be able to run reports and contact patients independently to schedule appointments. Member will have shadowed integral members of SHHC staff to plan orientation sessions.

• The supervisor assigns service activities in terms of project objectives and basic priorities and is available for consultation in resolving controversial issues.
• Member will independently run reports and plan orientation sessions, but will have on-going weekly check ins with supervisor as well as daily problem solving as needed.

• Completed projects are reviewed very generally to determine that objectives have been met and are in compliance with policies and regulations.
• Member and supervisor will discuss progress and outcomes on reports and orientation sessions.

• Written and oral guides provide specific instructions for doing service.
• Most instructions are easily memorized and require little interpretation
• Guidelines are generally applicable, but the Member independently makes adaptations in dealing with problems and unusual situations.
• Member will follow scheduling guidelines for scheduling appointments, but can be creative in both how to break up outreach call blocks and orientation sessions.

• Member has little or no choice about how to perform the service position
• The member must develop new techniques, methods, or approaches to complete service position assignments
• For scheduling internal appointments, member will follow guidelines for provider schedules. For orientation sessions, member will have flexibility to recreate format and structure.

• Member provides timely services of a personal nature to others
• Service position assignments involve a variety of conventional problems, questions, or situations that conform to established criteria
• Member will provide direct service in linking patients back into care. Member will also help patients problem solve barriers to care.

• Clients

• To provide customer service
• To give or exchange information
• Member will provide education through orientation sessions and help patients schedule appointments.

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.