Enhanced Care Management & Community Supports Peer Navigator (San Fernando Valley, CA)

Healthcare in Action • Los Angeles, CA

21d • $22 - $33 • Hybrid

About The Position

The Enhanced Care Management & Community Supports Peer Navigator supports members throughout the San Fernando Valley, Duarte, and surrounding areas who are experiencing homelessness, housing instability, or residing in temporary and interim housing settings. This position works closely with hospital social workers, case managers, discharge planners, interdisciplinary care teams, housing providers, and community-based organizations to support safe transitions from inpatient and outpatient settings into the community through person-centered care coordination, housing navigation, and continuity of care support. Many members supported through this role have complex medical and social needs and may be actively undergoing cancer treatment or other ongoing medical treatment requiring medically appropriate discharge planning, recuperative care, interim housing, or alternative placement options that support ongoing treatment and medical stability. In addition to supporting hospital-based referrals, this position will maintain a dually enrolled Enhanced Care Management (ECM) and Community Supports panel supporting members experiencing homelessness, housing instability, or residing in temporary and interim housing programs. This position is a patient-facing role. We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.

Requirements

• G.E.D./High School, required plus 3+ years of work experience as defined below.
• Associate's Degree plus 2+ years of work experience as defined below.
• Work Experience to include direct work experience, lived experience, training or volunteer work with patients experiencing homelessness, as well as those with active mental health and substance use conditions.
• Other demonstrated relevant experience in similar community settings, for example, working with other disadvantaged groups, and/or outreach will be considered.
• A comparable combination of education/experience and/or training will be considered equivalent to the education listed above.
• Ability to work in a dynamic, outdoors environment.
• Ability to work independently as well as part of a team.
• Ability to organize effectively.
• Ability to prioritize multiple and competing tasks.
• Ability to communicate effectively, including articulating one’s own relevant personal experiences.
• Excellent oral communication skills, as well as strong interpersonal skills.
• Maintenance of reliable transportation.
• Proficiency in operating a computer, including logging into and maneuvering around multiple systems such as online timesheets (time and attendance) and call center software.
• Travel 50% or more- Must have a valid driver’s license, automobile insurance, reliable transportation, and clean driving record.
• A background check is required.

Nice To Haves

• Bachelor’s degree preferred plus 1+ years of work experience as defined below.
• Experience supporting individuals with complex medical and social needs, including post-hospitalization discharge coordination, care transitions, hospital-based care coordination, recuperative care placement, or medically vulnerable populations preferred.
• Experience working with individuals experiencing acute or ongoing medical conditions requiring continuity of care, treatment adherence, or medically appropriate placement support strongly preferred.
• Demonstrated experience with ECM and CSS strongly preferred.
• HMIS/ Coordinated Entry System, preferred.

Responsibilities

• Collaborate closely with hospital social workers, case managers, discharge planners, and interdisciplinary care teams to support discharge planning, continuity of care, and transitions into the community.
• Conduct person-centered and trauma-informed care coordination and housing navigation activities consistent with CalAIM Enhanced Care Management (ECM) and Community Supports (CS) service expectations.
• Assist members in identifying and accessing interim housing, recuperative care, shelter placements, permanent supportive housing, and other medically appropriate placement options.
• Coach members to create and implement strategies that minimize risks associated with identified health conditions and barriers to care.
• Support members in obtaining identification documents, benefits enrollment, transportation resources, and linkage to medical, behavioral health, and community-based services.
• Coordinate and/or accompany members to medical and social services appointments as appropriate.
• Collaborate with housing providers, shelters, recuperative care programs, interim housing programs, and community organizations to facilitate placement opportunities and stabilization support.
• Support members who may not be appropriate for traditional shelter or housing environments due to ongoing medical treatment or clinical complexity.
• Conduct field-based outreach and community visits as needed to support ongoing engagement and continuity of care.
• Complete all required organizational, contractual, and CalAIM-specific documentation in a timely fashion, including documentation in EPIC and other required systems.
• Maintain accurate records of member engagement, care coordination activities, housing navigation efforts, and Plan of Care updates.
• Actively support the achievement of HIA’s Vision and Goals, particularly housing stability and improved health outcomes for members experiencing homelessness.
• Other duties as assigned.

Benefits

• Medical, Dental, Vision coverage
• An annual employee bonus program
• Robust Wellness Program
• Generous paid-time-off (PTO)
• 11 paid holidays per year, plus 1 additional floating holiday
• Excellent 401(k) Retirement Saving Plan with employer match.
• Robust employee recognition program
• Tuition reimbursement
• An opportunity to become part of a team that makes a difference to our members and our community every day!

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree