Community Health Worker, Enhanced Care Management

Heluna Health•Los Angeles, CA

20h•$23 - $25•Hybrid

About The Position

The Office of Diversion and Reentry (ODR) within the Los Angeles County Department of Health Services is seeking a dedicated Community Health Worker (CHW) to serve as a case manager on the Enhanced Care Management (ECM) Team. The ODR ECM program is intended to provide additional health and mental health resources, services and long-term support to individuals who are ODR clients. Clients in the ODR ECM program are referred to by Health plans as well as ODR programs. Services are coordinated by an ECM care team including the CHW who will work in collaboration with other clinical team members who work with the client as they transition from custody or who has been an ODR client but was referred for individualized case management, ensuring that their healthcare needs are met through enhanced services. The Community Health Worker coordinates multifaceted needs of the client from physical health, mental health, and housing care in collaboration with the multidisciplinary team and often in collaboration with contracted intensive case management service (ICMS) providers. Currently, ODR has a hybrid work schedule with a combination of workdays in the office, in the field and remote. This may change at discretion of DHS.

Requirements

Minimum 2 years working with unhoused, Justice Involved or seriously mentally ill clients.
Experience providing care support, community health collaboration, and direct client support.
Ability to work in the field and respond to community-based crisis situations.
Strong communication, empathy, and relationship-building skills.
Valid California driver’s license and ability to safely transport clients, per program needs.

Nice To Haves

Certification as a Community Health Worker, Peer Specialist, or related credential (or willingness to obtain).
At least 2 years of experience working with individuals with serious mental illness, co-occurring disorders, or complex trauma histories.
Familiarity with LPS processes, psychiatric hospitalizations, and Los Angeles County service systems (DHS, DMH, DPH, LAHSA, etc.).
Ability to speak a second language commonly used in Los Angeles County communities.

Responsibilities

Receives referrals from care partners, ODR social workers, court team, and ECM program staff for enrollment into ECM case management services.
Assist in identifying early signs of crisis and collaborate with providers and the ECM Coordinated Care Team to respond appropriately.
Oversee provision of ECM services, creation, and implementation of the patient tailored Care Plan.
Provide transportation support for clients during hospitalizations, evaluations, or other urgent care needs, following safety protocols and program guidelines.
Conduct Assessments and collaborate on developing Care Plans for enrolled clients
Coordinate Medical/Housing/Behavioral Health provider visits
Serves as an advocate for client/patient access to healthcare and community resources and assists clients in obtaining and completing benefit services as needed.
Offer emotional support, encouragement, and guidance to help clients engage with mental, physical and behavioral health treatment, housing services, and community resources.
Assist clients in understanding and navigating their care plans, appointments, and expectations from service providers and ECM team.
Provides emergency services to clients by making referrals to appropriate supportive agencies and arranging appointments and transportation.
Takes medical, mental health, family, social history and assists clients in completing necessary forms.
Facilitates client development of independent living skills and assisting with care plan goals and healthcare referrals and appointments.
Help coordinate with care team members and provider partners to ensure seamless service delivery through one-on-on case management and care coordination for the Member.
Offer services at the Member’s place of residence, where care is provided, or where services are most easily accessible within MCP guidelines.
Work collaboratively with ICMS teams, mental health clinicians, hospitals, and community health and behavioral health partners to support continuity of care.
Provide client-centered insights and observations that inform crisis planning, engagement strategies, and ongoing treatment approaches.
Advocate on behalf of Members with health care professionals.
Coordinate with hospital staff on discharge plan if/when Member is hospitalized.
Accompany Member to office visits, as needed and according to MCP guidelines.
Monitor treatment adherence (including medication)
Utilize program and partner databases to gather information regarding client care and documenting visits and care plan implementation and progress.
Conduct field-based outreach to locate clients who may be disengaged, at risk of crisis, or experiencing barriers to services.
Support motivation-building and engagement strategies that promote treatment adherence and housing stability.
Serve as a role model for recovery, resilience, and community reintegration.