Chronic Disease Specialist

Equal Opportunity Employer

The mission of the Health Federation of Philadelphia is to promote health equity for marginalized communities by advancing access to high-quality, integrated, and comprehensive health and human services.  Health equity is at the heart of all our work. We believe in and are firmly committed to equal employment opportunity for employees and applicants. We do not discriminate on the basis of race, color, national or ethnic origin, ancestry, age, religion, disability, sex or gender, gender identity and/or expression, sexual orientation, military or veteran status.  This commitment applies to all aspects of the Health Federation of Philadelphia’s employment practices, including recruiting, hiring, training, and promotion.


This position will work on two initiatives aimed at addressing chronic disease -  Million Hearts and the CDC Diabetes 2320. Million Hearts is a nationwide movement to reduce rates of uncontrolled hypertension, co-managed by the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS).  CDC Diabetes 2320 is a five-year cooperative agreement that aims to prevent or delay the onset of type 2 diabetes in adults with prediabetes, as well as enhance self-care practices, quality of care, and early detection of complications among people with diabetes. In collaboration with the National Association of Community Health Centers (NACHC), CDC, community-based organizations, and federally qualified health centers (FQHCs), HFP is striving to improve hypertension and diabetes outcomes for vulnerable populations in the Philadelphia region. The Chronic Disease Coordinator will assist in implementing both grants.

The Chronic Disease Coordinator will work closely with the Director of Special Projects, the CDC Project Director, and the Senior Director of Population Health to assist participating FQHCs in achieving improvement goals and grant strategies. The role involves developing project documentation, engaging health center staff, working directly with health center patients, and providing general administrative support to the project team. 

The Chronic Disease Coordinator will be responsible for managing data entry and collection for program tracking and evaluation activities related to the CDC Diabetes 2320 grant. This will involve overseeing data from various sources, such as the NDPP programs, Connect4Health/Findhelp platform, and population health management platforms. 

The position will report directly to the CDC Diabetes Program Director.



  • Coordinate Million Hearts project-related meetings.  These may be conducted in person or via conference call.  Will require scheduling, as needed, and providing general administrative support, including taking meeting notes/minutes, and sending follow-up communications.
  • Support health centers with the implementation of self-monitored blood pressure programs (SMBP). This includes providing patient education materials, tracking progress, and ordering equipment. 
  • Serve as a staff extender for patient enrollment into SMBP programs, as needed.
  • Engage health centers in the completion of the project activities. Assisting participating FQHCs in the completion of the roadmaps and intervention reports to track efficacy, reach, and sustainability.
  • Process reimbursements from partners and invoice incentive payments 
  • Manage data collection for NDPP classes - work with Lifestyle Coaches to collect individual participant data (weights and activity minutes) and log and track data to enable required program reporting
  • Train as an NDPP Lifestyle coach. Support Lead CHW and other staff in facilitating DPP groups as needed. 
  • Perform other duties as assigned.

Bachelor’s degree in public health, social work, sociology, health information technology or related field; 1-2 years of relevant program or project management experience; or a combination of education and experience that reflects the skills identified in this position description.


  • Proficient in Microsoft Excel
  • Experience with data collection and management
  • Strong written and verbal communication skills
  • Experience using tools like Microsoft Suite, Google Workspace, and Dropbox is a plus. Ability to quickly master new technology tools is essential.
  • Experience working with community health and human service agencies or programs; experience with Federally Qualified Health Centers preferred.
  • Outstanding interpersonal skills, with a background in interacting with culturally and racially diverse people and organizations.
  • Experience working directly with health center patient populations and supporting individuals with low health and digital literacy. 
  • Highly organized, with excellent time management skills, and systems-oriented.
  • Strong problem-solving and collaborative skills.
  • Demonstrated ability to work independently and as part of a team.

Position Type and Work Schedule: This is a full-time, non-exempt position.

Work Environment: Standard office setting, plus minimal scheduled travel for meetings, trainings, and technical assistance sessions with participating health centers.

Physical Demands: Able to sit and work at a computer keyboard for extended periods of time.  Able to lift and move up to 15 pounds.

COVID-19 Requirement: Proof of COVID-19 Vaccination must be produced upon hire.

Travel: Must be able to get around effectively within Philadelphia and surrounding counties, either on public transportation and/or in your own vehicle.  Limited travel beyond surrounding counties will be required, as well.

Salary and Benefits: Our employees are our most valuable resource, so we offer a competitive and comprehensive benefits package, which can include:

  • Medical with vision benefits
  • Dental insurance
  • Flexible spending accounts
  • Life,  AD&D and long term care insurance 
  • Short- and long-term disability insurance
  • 403(b) Retirement Plan, with a company contribution
  • Paid time off including vacation, sick, personal and holiday
  • Employee Assistance Program

Eligibility and participation is handled consistent with the plan documents and HFP policy.   


The Health Federation reserves the right to modify, interpret, or apply this job description in any way the Company desires. The above statements are intended to describe the general nature and level of work being performed by an employee assigned to this position. This job description in no way implies that these are the only duties, including essential duties, responsibilities and/or skills to be performed by the employee occupying this position. This job description is not an employment contract, implied, or otherwise. The employment relationship remains “at will.” The aforementioned job requirements are subject to change to reasonably accommodate qualified disabled individuals.