ECM - Community Health Worker (on-site)

San Diego American Indian Health Center•San Diego, CA

5d•Onsite

About The Position

We are an FQHC community health center dedicated to embodying the values central to American Indian cultures. This includes respect for our patients, acknowledgement of the whole person, and a focus on working together to ensure health for the individual, and therefore the community. We invite persons of all tribes, ethnic backgrounds and walks of life to experience the comprehensive care we deliver and to contribute to the services we provide for children, youth, families, adults, and elders. Summary: The Community Health Worker (CHW) is a trusted frontline public health worker who improves the health and well-being of patients and families through culturally competent outreach, education, and care coordination. The CHW plays a key role in Enhanced Care Management (ECM) by providing patient navigation, health system support, and assistance with accessing insurance and social service resources. This role bridges gaps between patients and providers, ensuring individuals can access the right care at the right time.

Requirements

High School Diploma or GED required, Associate’s degree or higher preferred.
Certification as a Community Health Worker or become certified in first 90 days
Experience in case management, ECM, insurance enrollment, or navigation strongly preferred.
Strong knowledge of Medi-Cal, Medicare, and commercial insurance systems.
Lived experience or strong ties to the community served.
Excellent communication, organizational, and cultural competency skills.
Valid driver’s license and reliable transportation required.
CPR/ BLS certification: Maintain a current Basic Life Support (BLS) certification issued by the American Heart Association (AHA), the American Red Cross, or an equivalent organization. Certification must include an in-person, hands-on skills assessment. Online-only certifications are not accepted.
Annual background checks: Consent to annual background checks as a condition of continued employment, to ensure compliance with organizational standards and eligibility requirements.
For-Cause Drug Screening: Comply with drug screening requirements when initiated by the organization for cause, to support a safe, compliant, and drug-free workplace.
Ongoing Compliance Requirements: Maintain up-to-date compliance with all required annual renewals, including professional licenses, certifications, physical examinations, TB testing, and mandatory regulatory trainings as assigned by the San Diego American Indian Health Center (SDAIHC).
Commitment to patient-centered, team-based care.
Knowledge of infection control, OSHA, HIPAA, and safety standards.
Excellent interpersonal, organizational, and problem-solving skills.
Demonstrated ability to multitask in a fast-paced environment.
Competency in using EHR systems (ECW or similar preferred).
Professional demeanor, adaptability, and dependability.

Responsibilities

Conduct targeted outreach to high-need individuals and families, including those eligible for ECM services.
Build trusting, sustainable relationships with patients and the community.
Participate in community events, health fairs, and partner meetings to identify and connect patients to services.
Conduct presentations at various community sites including at schools, churches, food banks, work sites, WIC offices and other community-based organizations regarding SDAIHC services and healthcare coverage.
The CHW informs the community regarding changes in public programs, new coverage opportunities and retention of coverage. The CHW will represent SDAIHC at health fairs and community events as assigned.
Conducts in-reach and education for uninsured patients or those who have lost coverage.
Accurately completes patient registration when indicated for new patients including demographic information and household assessment according to policies and procedures. Maintains accurate and current information in the practice management system when there are changes in eligibility.
Provides assistance and helps families or individuals who face access, utilization/service, or retention (staying in the program) problems. Communicate effectively with program representatives and eligibility workers to identify interventions that assist the applicant in the resolution of limiting barriers to eligibility. Assist applicants to resolve communication barriers regarding eligibility by conducting three-way phone calls, contacting the appropriate agency, and educating the applicant as to the required documentation.
Outreach must begin as soon as 4 business day from the time SDAIHC receives the member list or member information.
5 attempts to outreach within 60 days (at least 1 face-to-face, final attempt by mailed letter if not homeless
10 business days window for new member assignment notices
Outreach is encounter-based and expected promptly, primarily in person, supplemented with phone/text/mail as needed
Outreach must be thoroughly documented same day and tracked as it is reimbursable by the health plans
At initiation of ECM: Assign a Lead Care Manager and develop an individualized Care Plan
Serve as the patient’s primary navigator for ECM services, coordinating care across medical, behavioral health, dental, specialty care, and community-based services.
Conduct health risk assessments and social determinants of health screenings to identify patient needs.
Support patients in scheduling and preparing for appointments, follow-up visits, and referrals.
Work closely with care managers, providers, and external partners to align care plans and reduce barriers.
Accompany patients to appointments as appropriate to provide advocacy and support.
Assist patients with insurance enrollment, re-determination, and understanding benefits (e.g., Medi-Cal, Medicare, Covered California).
Educate patients on how to use their insurance, choose primary care providers, and access covered services.
Provide guidance on sliding fee discounts, patient assistance programs, and other financial resources.
Connect uninsured or underinsured patients to coverage options or community resources.
Deliver culturally appropriate health education on chronic disease management, preventive services, and wellness.
Support patient self-management goals and provide coaching on lifestyle changes.
Facilitate small group sessions, workshops, or talking circles to promote health literacy and peer support.
Accurately document all encounters, care coordination activities, and outreach efforts in the Electronic Health Record (EHR) and program databases.
Ensure compliance with FQHC, HRSA, FTCA, and Medi-Cal ECM program requirements.
Track and report performance measures, referrals, and patient outcomes for quality improvement.
Participate in multidisciplinary case conferences to support integrated patient care.
Maintain strong relationships with internal departments (medical, dental, behavioral health) and external agencies (housing, food banks, insurance navigators, tribal and community organizations).
Provide feedback to supervisors on emerging community needs and gaps in services.
Receive Certification with Covered California within a week of hire
20 community events to outreach those who do not have insurance
Work with Marketing to post 10 paid media Covered California enrollment assistance posts
Work with Marketing to post 10 social media Covered California enrollment posts
Outbound Call Campaigns to general new leads.
Minimum 16 application assistance
Assist patients or potential patients with enrollment assistance or renewal
Attend bi-monthly outreach, eligibility, and enrollment workgroup meetings with HQP