Assists patients by linking them to a broad range of services, including, but not limited to, healthcare support services, social work, GIM resource navigator, specialty department navigators, financial assistance, child-care, housing, food, clothing, transportation, food pantries, and appropriate community resources. The Population Health Specialist will assist in case management services for GIM Primary Care patients, developing a service plan based on identified needs, facilitating access to social service benefits and other internal and external resources, monitoring the patient's progress, and tracking practice performance.