Community Health Worker (CalAIM - ECM & Community Supports)

Community HealthWorks•Sacramento, CA

2d•Hybrid

About The Position

Under the supervision of the Project Manager, in partnership with health plans and clinical providers, the Community Health Worker (CHW) works primarily in the field to build relationships with people experiencing homelessness and/or multiple chronic health conditions. The CHW provides hands-on advocacy and assists with connection to health services, housing, and other social services through direct field work and community engagement. The primary goal for a CHW is to assist persons experiencing homelessness or various chronic physical and mental health conditions to access health, behavioral health, housing, and social services through CalAIM (California Advancing and Innovating Medi-Cal) through the specific programs Enhanced Care Management (ECM) (care coordination services) and Community Supports (CS) (housing navigation services). The CHW will develop familiarity with various medical conditions and provide knowledgeable support to clients managing complex health needs. The CHW will administer assessment tools, facilitate placement into emergency shelter housing, and connect to social services while maintaining a manageable caseload capacity. CHWs provide person-centered long-term case management with an emphasis on helping clients achieve their housing and health goals. The CHW will learn to navigate Sacramento’s housing system, government benefits, and medical systems of care. The CHW will also assist program enrollees in obtaining or maintaining health insurance, establishing care with a primary medical home, following up on health care needs, and advocating with medical providers and health plans on behalf of clients. When applicable, the CHW will connect eligible persons with County Mental Health and System of Care services. The CHW will work as part of a larger team within Community HealthWorks and engage with various other community agencies and local service providers. This position requires approximately 60% field work and 40% office-based activities.

Requirements

High School diploma or GED required.
A current CA Class C Driver’s License, proof of auto insurance are required and a clean driving record.
Must have reliable transportation and be able to travel within Sacramento County and surrounding counties.
Must complete a criminal background check.
All Community HealthWorks employees must be fully vaccinated against COVID-19, unless a medical or religious exemption is approved. Employees with an approved exemption will be required to get tested for COVID-19, at least twice-weekly.

Nice To Haves

Bachelor’s or Master’s Degree in social work or other related field preferred.
Certified Drug & Alcohol Counselor (CDAC) preferred.
Certification in Behavioral Health preferable.
Experience working with unsheltered individuals experiencing complex health issues is desirable.
Experience as a health navigator, peer support worker, outreach worker or promotora is desirable.
Substance Use Disorder (SUD) experience preferred.

Responsibilities

Provide support, empowerment, mentorship, and education for individuals with health challenges, including substance use and mental health issues through primarily field-based interactions.
Perform telephonic and in-person outreach to lists of Medi-Cal beneficiaries identified due to high utilization of emergency medical care, homelessness status, and/or various chronic conditions.
Work collaboratively with identified agency partners to conduct outreach in the community, focusing on those who are most vulnerable.
Work in various field environments, including shelters, homeless encampments, and various government and medical institutions.
Accompany and support clients during medical appointments, social service visits, housing opportunities, and other critical appointments.
Provide crisis intervention support when situations arise, while understanding organizational limitations as a non-crisis prevention agency.
Distribute essential resources including food, clothing, and water to clients in need.
Work closely with justice-impacted individuals, including those with probation and parole experience.
Provide legal advocacy support as part of client services.
Work with and advocate to clients' health plans to ensure appropriate care and services.
Assist clients in connecting to appropriate housing services and support, navigating Sacramento's housing market, and facilitating housing location, paperwork, and move-in processes.
Assist in obtaining health coverage insurance and housing readiness documentation such as ID, social security card, and income verification, including coordination of transportation to appointments as necessary for clients on caseload.
Perform health and housing assessments, review client medical records, and submit referrals to various services and programs.
Work with team of Health Navigators to confirm health coverage and ensure comprehensive health services, nutrition programs, and other community resources.
Maintain complete client records, daily activity logs, mileage logs, and other reports as directed using appropriate computer skills and documentation systems.
Maintain clients' confidentiality and strict adherence to HIPPA requirements.
Coordinate with internal and external navigators from other agencies to ensure collaborative outreach approach.
Establish and maintain positive, productive working relationships with mental health programs, shelter programs, law enforcement, and providers of community services.
Demonstrate professionalism when interacting with government officials, health plans, and other agencies.
Attend team meetings, case conferences, training workshops, and community meetings as needed.
Participate in onboarding new staff through shadowing and reverse shadowing training models.
Engage in ongoing on-the-job training and education, with emphasis on learning while working.
Maintain and participate in all job-related training, certifications, and renewals such as Mental Health First Aid, Motivational Interviewing, and Certified Enrollment Counselor/Certified Application Counselor certification.
Regular attendance
Other duties as assigned