Community Health Worker, CalAIM – ECM (Justice-Involved Population)

Community HealthWorks•Sacramento, CA

1d•$25 - $31•Remote

About The Position

Community HealthWorks (CoHeWo) advances health equity by helping individuals and families access the health coverage, care, housing support, and community services they need to thrive. We work at the intersection of healthcare and community support, partnering with managed care plans, health systems, community-based organizations, and government agencies to remove barriers to care. Community Health Workers are central to this work. They serve as trusted connectors who help people understand complex systems, identify their own goals, and take practical next steps toward greater health and stability. The Community Health Worker, CalAIM works primarily in the community with Medi-Cal members receiving Enhanced Care Management (ECM). This assignment focuses on members transitioning from incarceration into the community who may also be experiencing multiple chronic health conditions, behavioral health needs, substance use, housing instability, disrupted access to healthcare or medications, or other barriers to care. Through Enhanced Care Management, the CHW provides post-release engagement, care coordination, and reentry support to help members address complex health and social needs and maintain connections to care and services following release. The CHW works closely with the Pre-Release Care Coordinator, clinical team, health plans, healthcare providers, community partners, and other CoHeWo teams to support continuity of care and address barriers to successful community reintegration. The CHW carries an active caseload and works with members to identify their goals, understand available options, and take practical next steps toward greater health and stability. This is a non-clinical, non-supervisory role. This is a relationship-based, field-focused position. Approximately 60% of the work takes place in the community and 40% involves documentation, phone outreach, service coordination, team meetings, and follow-up. Work may occur in shelters, homes, clinics, hospitals, government offices, housing locations, community-based organizations, and other partner sites. For this assignment, care coordination is focused on supporting members as they transition from incarceration back into the community. For this assignment, the CHW provides ongoing ECM services to members transitioning from incarceration back into the community. When CoHeWo is the member’s selected ECM provider, the CHW participates in the warm handoff from pre-release services, takes the member onto their ECM panel, and provides ongoing community-based care coordination following release. Needs and circumstances can change quickly during reentry. A healthcare appointment may need to be scheduled or rescheduled, medications may need follow-up, housing or transportation plans may change, or new needs may emerge after release. The CHW helps the member navigate these changes while coordinating with appropriate healthcare, community, and justice-system partners. The work requires flexibility, clear communication, sound judgment, professional boundaries, and the ability to work independently while remaining connected and accountable to the team.

Requirements

High school diploma or GED.
Ability to build respectful relationships with people from varied backgrounds and life circumstances, including people transitioning back into the community after incarceration.
Clear communication, organization, confidentiality, attention to detail, and consistent follow-through.
Ability to listen, identify needs and goals, explain complex information clearly, and support practical next steps.
Ability to coordinate respectfully with healthcare, community, government, and justice-system partners.
Comfort learning and using electronic documentation systems, email, and Microsoft Office tools.
Ability to work independently in community settings while remaining accountable and connected to a team.
Valid California Class C driver’s license, current auto insurance, reliable transportation, and ability to travel throughout Sacramento County and surrounding areas.
Completion of a criminal background check. Findings will be reviewed in relation to the position and in accordance with organizational policy and applicable law.
Compliance with health-screening, certification, safety, and partner-site requirements applicable to the assignment.
Maintenance of required training, certifications, and renewals associated with the role.

Nice To Haves

Relevant experience may come from paid work, volunteering, education, caregiving, community involvement, or lived experience that you choose to share.
Community health, outreach, peer support, case management, health navigation, housing services, behavioral health, substance-use services, or work alongside people experiencing homelessness.
Experience working with people affected by incarceration and returning to the community.
Experience coordinating across healthcare, social-service, government, or justice systems.
Knowledge of Medi-Cal, CalAIM, Enhanced Care Management, Sacramento’s health care, housing and benefits systems, or local health and social-service resources.
Community Health Worker, peer-support, substance-use, behavioral-health, or health-coverage enrollment training or certification.
Postsecondary education in social work, behavioral health, public health, criminal justice, or a related field.

Responsibilities

Conduct in-person and telephone outreach to Medi-Cal members receiving Enhanced Care Management.
Build respectful, trusting relationships and help members identify their goals, understand their options, and take practical next steps.
Provide post-release engagement and reentry support to members transitioning from incarceration into the community.
Participate in and complete warm handoffs for members transitioning from pre-release services to CoHeWo for ongoing ECM services.
Review the member’s existing care plan, identified needs, referrals, and community connections and continue care coordination following release.
Meet members in community settings and accompany them to medical, housing, benefits, and other important appointments when appropriate.
Connect members with essential resources such as food, clothing, water, shelter, transportation, and community-based services.
Provide support during urgent or emotionally difficult situations, follow organizational safety and escalation practices, and recognize the limits of CoHeWo’s non-emergency role.
Complete required health and social-needs assessments and develop or update care plans with members.
Help members establish or reconnect with primary care and other healthcare providers following release.
Support scheduling and follow-through for medical, behavioral-health, or other healthcare appointments.
Help address medication-related needs following release by coordinating with appropriate healthcare, pharmacy, or clinical partners.
Help members maintain health coverage, follow up on healthcare needs, and communicate with health plans and providers.
Connect eligible members with behavioral health, substance-use, County Mental Health, System of Care, and other appropriate services.
Recognize when a healthcare or medication-related need is outside the CHW’s role and involve the appropriate clinical provider or team member.
Coordinate with the Pre-Release Care Coordinator to support continuity of care and services as members transition into the community.
Follow up on referrals, appointments, services, and other needs identified before release.
Help members address housing, transportation, identification, benefits, employment, and other social needs that may affect health and stability following release.
Support housing navigation, including housing-readiness documents, referrals, applications, prospective housing opportunities, and move-in coordination.
Help members obtain identification, Social Security cards, income verification, and other documents needed to access services, benefits, or housing.
Coordinate with healthcare providers, health plans, community-based organizations, other CoHeWo teams, and justice-system partners as appropriate to the member’s care and reentry needs.
Coordinate with probation or parole when appropriate and relevant to the member’s care coordination needs.
Help reduce gaps and duplication as members move between healthcare, community, and other service systems.
Maintain timely, complete, and accurate member records, service notes, assessments, activity logs, mileage logs, referrals, and required reports.
Document coordination, referrals, follow-up needs, and outstanding next steps so members can receive informed and continuous support.
Use assigned electronic systems and standard office technology to track services, follow-up needs, and outcomes.
Protect member privacy and comply with HIPAA, confidentiality requirements, and organizational policies.
Participate in supervision, team meetings, case conferences, training, and community meetings.
Communicate changes, safety concerns, barriers, and situations requiring guidance to the appropriate supervisor or team member.