CalAIM Community Health Worker - Solano County

Pacific Health Group • Suisun City, CA

81d • $21 - $24

About The Position

At Pacific Health Group, we are at the forefront of revolutionizing healthcare, and you will play a vital role in this mission. We are dedicated to improving health outcomes by addressing social determinants of health and coordinating comprehensive community-based services, particularly through our CalAIM programs. If you are passionate about making a difference and have the skills to lead in this dynamic environment, we invite you to join our team. The CalAIM Community Health Worker (CHW) serves as a vital link between healthcare systems and vulnerable populations under California's CalAIM (California Advancing and Innovating Medi-Cal) initiative. This role focuses on addressing social determinants of health, improving health outcomes, and reducing health disparities in underserved communities through direct service delivery, community outreach, and comprehensive care coordination.

Requirements

• High school diploma or equivalent; Associate's or Bachelor's degree in a related field preferred
• Prior Community Health Worker certification highly desired; willingness to obtain certification within 18 months of hire if not already certified
• Minimum of 2 years of experience in community health, social services, or related field
• Strong understanding of local community resources and social determinants of health
• Excellent interpersonal and communication skills
• Proficiency in electronic health records and basic computer applications
• Bilingual skills (English/Spanish, or other relevant languages) preferred
• Possess a valid California Driver’s License (Class C minimum), maintain a personal, operable vehicle for daily business use, and carry current liability insurance that meets California's minimum legal requirements

Nice To Haves

• Experience with chronic conditions including diabetes, hypertension, COPD, mental health disorders, and substance use disorders
• Knowledge of Medi-Cal policies and billing procedures

Responsibilities

• Develop and maintain written Plans of Care for each member (maximum 12-month duration)
• Conduct comprehensive ADL and other assessments to support care planning
• Provide up to 12 units (6 hours) of care per member per recommendation period
• Perform health screenings and assessments using standardized tools including: Social Determinants of Health Assessment (SDOH 5-Q), PHQ-9 and PHQ-2 mental health screenings, Hunger Vital Sign Screening Tool, Functional status and ADLs assessments
• Conduct in-home environmental trigger assessments for asthma patients (up to 2 visits annually)
• Provide health education using standardized curricula consistent with established healthcare standards
• Offer coaching and goal setting to improve members' health and self-management abilities
• Facilitate health navigation services to help members access care and understand healthcare systems
• Connect members to community resources necessary to promote health
• Address healthcare barriers including medical translation/interpretation and transportation services
• Serve as cultural liaison and assist licensed providers in care plan development
• Conduct community outreach to identify and engage high-risk, hard-to-reach individuals
• Organize and participate in health screening and wellness fairs
• Coordinate mobile health clinics and vaccination drives
• Facilitate community walks, fitness events, and wellness activities
• Distribute hygiene and wellness kits, coordinate food and nutrition drives
• Canvas neighborhoods to identify social determinants of health
• Facilitate group sessions for up to 8 Medi-Cal members per billable session
• Lead workshops on various health topics including domestic violence psychoeducation, tobacco cessation, violence prevention, stress management, immunization education, and housing assistance
• Assist members with enrollment in government assistance programs
• Provide individual support and advocacy to prevent health condition onset or exacerbation
• Offer language/medical translation services
• Schedule medical appointments and provide transportation coordination
• Maintain accurate and timely documentation of all client interactions and outcomes
• Collaborate with interdisciplinary care teams including RNs and licensed providers
• Participate in case conferences and team meetings
• Enter and maintain electronic health records and compile reports
• Complete billing using appropriate CPT codes

Benefits

• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED
• Number of Employees: 51-100 employees