Clinical-Community Linkages Specialist

Job Type

Full Time




New York
New York
United States


The Fund for Public Health in New York City (FPHNYC) is a 501(c)3 non-profit organization that is dedicated to the advancement of the health and well-being of all New Yorkers. To this end, in partnership with the New York City Department of Health and Mental Hygiene (DOHMH), FPHNYC incubates innovative public health initiatives implemented by DOHMH to advance community health throughout the city. It facilitates partnerships, often new and unconventional, between government and the private sector to develop, test, and launch new initiatives. These collaborations speed the execution of demonstration projects, effect expansion of successful pilot programs, and support rapid implementation to meet the public health needs of individuals, families, and communities across New York City.



As part of the NYC Department of Health and Mental Hygiene (DOHMH), the Bureau of Primary Care Information Project (PCIP) is devoted to improving health by promoting and supporting primary care. PCIP works with over 1,300 health care organizations on increasing clinical prevention opportunities, reducing health disparities, managing/preventing chronic disease, and creating community linkages to support health promotion.


Many of the activities and services to primary care are funded by grants and delivered through the New York City Regional Electronic Adoption Center for Health (NYC REACH) devoted to promoting and supporting the adoption of the chronic care model; using payment reform to advance population health by advocating and promoting reforms and programs that will facilitate the delivery of quality primary care; and monitoring the New York City healthcare system by leveraging data to monitor quality of care and population health to inform public health decisions. To learn more, visit us at or



The Clinical-Community Linkages Specialist will work on Diabetes Prevention Program and Diabetes Self-Management Program as well as other self-management programs in communities within NYC.  These targeted communities have substantially higher than city average rates of obesity, pre-diabetes, diabetes, hypertension and related mortality. Culturally responsive and place-based environmental strategies, lifestyle change programs and health system collaborations are needed to make a positive impact on health outcomes in these communities.

This position will report to the Manager of Clinical-Community Program Linkages, and will be responsible for the coordination of clinical organizations’ capacity to host and deliver Evidence Based Interventions (EBIs) with the aim of increasing access to and enrollment in these wellness programs. The Clinical-Community Linkages Specialist will focus on connecting patients with community resources to increase engagement in lifestyle change. This work will require close collaboration with a variety of stakeholders including members of the Diabetes Prevention Recognition Program and Self-Management Resource Center program providers, as well as healthcare providers who will recruit and refer clients to these services. The Clinical-Community Linkages Specialist may also assist in identifying opportunities and incentives for collaboration as well as providing integrated workflows for providers to follow.



  • Provide guidance, training, and technical assistance for clinical organizations to develop sustainable prevention and self-management intervention programming and workshops with an emphasis on cultural responsiveness
  • Create and support EBI workforce development efforts including performing trainings and developing supporting materials for EBI coaches and peer leaders
  • Perform Evidence Based Intervention lifestyle coaches and peer leader trainings for a diverse audience from both clinical and community organizations. Implement modifications to the curriculum for the coaches’ training on an as needed basis
  • Lead National DPP workshops as part of a broader worksite wellness initiative. This will require sensitivity to the privacy of the participants, as they are coworkers, and other worksite wellness concerns including work related stress  
  • Offer technical assistance and training to peer leaders in workshops developed and accredited by the Self-Management Resources Center
  • Perform quality control measure activities in collaboration with PCIP’s Quality Improvement team to ensure referrals are being processed in a timely manner
  • Monitor quality control measures related to post enrollment indicators (such as number of workshops hosted, workshop attendance, completion and attrition, weight lost, A1C, etc.)
  • Aggregate the data to summarize trends (such as dropout rate by geography and socioeconomic indicators, completion rates, weight loss rates, etc.)
  • Develop close working relationships with a variety of clinical and community based organizations
  • Relay messaging and coordination plans between multiple stakeholders 
  • Leverage other NYC DOHMH initiatives for mutually reinforcing strategies to create streamlined efforts for chronic disease prevention and management
  • Conduct needs assessments with our clinical and community partners
  • Other duties, as assigned



  • Bachelor’s degree; Master’s degree a plus.
  • Two plus years of relevant work experience including involvement in Quality Improvement, PCMH, and/or Meaningful Use initiatives
  • Self-starter who takes initiative
  • Ability to travel within the 5 boroughs of NYC
  • Advanced skills in data management as well as the ability to analyze and present data to groups and individuals
  • Excellent relationship management and communication skills


·        Master’s Degree in public policy, public health, health administration, public administration, or related field; 3 or more years of professional experience in working with clinicians and community based organizations

·        Certified National Diabetes Prevention Master Trainer / Lifestyle Coach 

·        Certified Master Trainer / Peer Leader in the Self-Management Resource Center workshops

·        Fluency in Spanish, Haitian Creole, Korean and/or Bengali or other languages relevant in underserved communities in New York City

·        Strong computer, time management, relationship management and organizational skills

·        Experience working with a variety of partners/stakeholders in both clinical and community based settings

·        Commitment to team work

·        Willing to travel regularly within communities in Brooklyn, Bronx, Manhattan, Queens and Staten Island

·        Excellent knowledge of the Microsoft suite of products with a particular focus on Word, Excel, Power Point and Publisher



There is potential for this position to transition to DOHMH and therefore candidates must meet DOHMH eligibility requirement including NYC residency.


FPHNYC offers a comprehensive benefits package. The salary range for this position is commensurate with experience.

Professional Level

None specified

Minimum Education Required

No requirement

How To Apply

To apply, send Resume, with Cover Letter, including how your experience relates to this position, to indicating “Clinical-Community Linkages Specialist_your name” in subject line. 


The Fund for Public Health in New York City is an Equal Opportunity Employer and encourages a diverse pool of candidates to apply.