Community Health Worker

Job Summary:

The Community Health Worker (CHW) serves as a trusted liaison between community members, healthcare providers, and social service organizations. Working as an integral, mostly remote member of the pod's interdisciplinary Care Team, alongside Lead Care Managers, MAs, and RNs, the CHW is responsible for conducting outreach, providing health education, addressing social determinants of health, and connecting members to medical, behavioral health, and community-based resources. Under the general supervision of Enhanced Care Management Leadership, the CHW works closely with members, families, care teams, and community partners to improve health outcomes, promote self-sufficiency, and reduce barriers to care; working mainly remotely alongside the Lead Care Managers for direct member engagement. This position requires strong communication skills, cultural sensitivity, and a passion for serving diverse populations.

Responsibilities:

• Serve as the primary team member to conduct in-person visits to community members and provide education on health-related topics.

• Assist individuals in accessing healthcare services, social services, and community resources.

• Assess social determinants of health and identify barriers impacting member well-being and healthcare access.

• Support care coordination activities and collaborate with healthcare providers, care managers, social workers, and community agencies.

• Function as an integral, mostly remote member of the pod Care Team, partnering closely with Lead Care Managers, MAs, and RNs who conduct direct member engagement.

• Accompany members to appointments when appropriate and assist with healthcare system, insurance program, and benefit enrollment navigation.

• Maintain ongoing contact with members through phone calls, home visits, community outreach, and telehealth platforms.

• Document member interactions, assessments, and referrals accurately and timely in designated systems.

• Advocate for members and assist with resolving barriers that interfere with access to care and services.

• Participate in community outreach events, health fairs, educational workshops, and engagement activities.

• Maintain member confidentiality and comply with all organizational and regulatory requirements.

• Participate in regularly scheduled member huddles for updates and feedback.

• Reporting in-person to the office as needed for meetings.
• Perform additional duties as assigned.

Populations of Focus:

• Individuals experiencing homelessness: Lacking a fixed, regular, and adequate nighttime residence.

• Individuals at risk for avoidable hospital or emergency department utilization: Five or more emergency room visits in a six-month period that could have been avoided with appropriate outpatient care or improved treatment adherence.

• Individuals with Serious Mental Health and/ or substance use disorder needs: Adults who meet the eligibility criteria for participation in, or obtaining services through Specialist mental health services or the Drug Medi-Cal organized delivery system or Drug Medi-Cal program.

• Individuals transitioning from incarceration/Justice Involved: Adults transitioning from a correctional setting or transitioned from a correction setting within the past 12 months, or children and youth who are transitioning from a youth correctional facility or transitioned from being in a youth correctional facility within the past 12 months.

• Adults living in the community and at risk for long-term care institutionalization: Adults who are living in the community who meet the SNF Level of Care criteria; or who require lower-acuity skilled nursing or equipment for prevention, diagnosis, or treatment of acute illness or injury.

• Adult nursing facility residents transitioning to the community: Adult nursing residents who are interested in moving out of the institution, and are likely candidates to do so successfully, and are able to reside continuously in the community.

• Children and youth enrolled in California Children’s Services (CCS) or CCS Whole Child Model (WCM) with Additional Needs Beyond the CCS condition: Children and youth enrolled in CCS or CCS WCM and are experiencing at least one complex social factor influencing their health.

• Children and Youth Involved in Child Welfare

• Individuals with Intellectual/ Developmental Disabilities: Adults who have a diagnosed I/ DD and qualify for eligibility in any other adult ECM population of focus.

• Pregnant and Postpartum individuals; Birth Equity Population of Focus: Adults and youth who are pregnant or postpartum and qualify for eligibility in any other adult or youth ECM POF, or are subject to racial and ethnic disparities.

Education and Experience:

• High school diploma or GED required.

• Minimum of 1 year experience in case management, member care, customer
  service, call center, or member care required.

• Community Health Worker (CHW) certification required.

• Valid California driver's license and valid vehicle insurance required.

Required Skills/Abilities:

• Excellent communication, interpersonal, customer service and organizational skills.

• Ability to engage effectively with individuals from diverse cultural, ethnic, and socioeconomic backgrounds.

• Strong knowledge of community resources and social service systems.

• Computer skills for documentation, email communication, and electronic health record systems.

• Ability to work independently and collaboratively as part of a multidisciplinary care team.

• Strong organizational, time-management, and problem-solving abilities.

• Ability to handle sensitive information with professionalism and confidentiality.

• Demonstrated ability to advocate for members and navigate complex healthcare and social service systems.

• Proficiency in multitasking while managing a caseload and meeting program requirements.

• Ability to exercise sound judgment and maintain composure in challenging situations.

Physical Requirements:

• Must be able to travel using personal vehicle to complete outreach visits. Travel for in-person office visits will be as needed. Mileage reimbursement for the use of your vehicle is at a standard rate.

• Reliable high-speed internet and a private, HIPAA-compliant home workspace suitable for a mostly remote support role.

• Prolonged periods of sitting, standing, walking, driving, and working on a computer.

• Ability to navigate community environments, including homes, clinics, shelters, and community agencies.

• Lifting: Able to lift up to 15lbs.