CalAIM Community Health Worker - Solano County
3 days ago
Benicia
Job Description CalAIM Community Health Worker Job Description Job Title: CalAIM Community Health Worker Reports to: Community Health Program Manager Pay: $21 - $24 per hour Position Type: Full-Time Job Summary At Pacific Health Group, we are at the forefront of revolutionizing healthcare, and you will play a vital role in this mission. We are dedicated to improving health outcomes by addressing social determinants of health and coordinating comprehensive community-based services, particularly through our CalAIM programs. If you are passionate about making a difference and have the skills to lead in this dynamic environment, we invite you to join our team. The CalAIM Community Health Worker (CHW) serves as a vital link between healthcare systems and vulnerable populations under California's CalAIM (California Advancing and Innovating Medi-Cal) initiative. This role focuses on addressing social determinants of health, improving health outcomes, and reducing health disparities in underserved communities through direct service delivery, community outreach, and comprehensive care coordination. Target Populations Served CHWs will work with qualifying Medi-Cal members who have one or more of the following criteria: • Presence of known risk factors (domestic violence, tobacco use, excessive alcohol use, drug misuse), • One or more emergency department visits within the previous six months, • One or more hospital inpatient stays within the previous six months or at risk of institutionalization, • One or more detox facility stays within the previous year, • Two or more missed medical appointments within the previous six months, • Expressed need for health system navigation or resource coordination, • Need for preventive services (immunizations, dental visits, well-child care), • Experience with community violence or chronic exposure to violence, • Asthma requiring self-management education or environmental assessments Key Responsibilities Direct Patient Services • Develop and maintain written Plans of Care for each member (maximum 12-month duration), • Conduct comprehensive ADL and other assessments to support care planning, • Provide up to 12 units (6 hours) of care per member per recommendation period, • Perform health screenings and assessments using standardized tools including:, • Social Determinants of Health Assessment (SDOH 5-Q), • PHQ-9 and PHQ-2 mental health screenings, • Hunger Vital Sign Screening Tool, • Functional status and ADLs assessments, • Provide health education using standardized curricula consistent with established healthcare standards, • Offer coaching and goal setting to improve members' health and self-management abilities, • Facilitate health navigation services to help members access care and understand healthcare systems, • Connect members to community resources necessary to promote health, • Address healthcare barriers including medical translation/interpretation and transportation services, • Conduct community outreach to identify and engage high-risk, hard-to-reach individuals, • Organize and participate in health screening and wellness fairs, • Coordinate mobile health clinics and vaccination drives, • Facilitate community walks, fitness events, and wellness activities, • Distribute hygiene and wellness kits, coordinate food and nutrition drives, • Facilitate group sessions for up to 8 Medi-Cal members per billable session, • Lead workshops on topics including:, • Domestic violence psychoeducation and safety planning, • Tobacco cessation and effects of substance use, • Violence prevention and coping skills, • Stress management and mental health awareness, • Child/adolescent immunization education, • Healthy relationships and communication skills, • Assist members with enrollment in government assistance programs (food stamps, SSDI, SSI, utility assistance), • Provide individual support and advocacy to prevent health condition onset or exacerbation, • Offer language/medical translation services, • Schedule medical appointments and provide transportation coordination, • Accompany patients to appointments as needed, • Maintain accurate and timely documentation of all client interactions and outcomes, • Complete required activity notes documenting outreach attempts and services provided, • Update Plans of Care at 6-month intervals to determine progress, • Collaborate with interdisciplinary care teams including RNs and licensed providers, • Participate in case conferences and team meetings, • Enter and maintain electronic health records and compile reports, • Cultural competency and sensitivity to diverse populations, • Ability to build trust and rapport with clients from various backgrounds, • Strong problem-solving and critical thinking skills, • Excellent time management and organizational abilities, • Flexibility to work in various settings, including clients' homes and community locations, • Understanding of chronic conditions including diabetes, hypertension, COPD, mental health disorders, and substance use disorders, • Hybrid work environment: approximately 65% field-based work, 35% remote work from home, • County-specific assignment (Humboldt, Shasta, or Solano County) requiring extensive travel within the assigned county for field work, • Remote work includes documentation, virtual workshops, telehealth services, and administrative tasks, • Field work includes home visits, community events, in-person workshops, and direct member services, • Regular attendance at community events, including evenings and weekends as needed, • Dual documentation requirements using both Partnership Health Portal and Pacific Health Group systems, • Public speaking and presentation responsibilities at community events, • Ability to lift up to 25 pounds and stand for extended periods during community events, • Work in diverse community settings including homes, community centers, and outdoor venues, • Maximum of 4 units (2 hours) of services per member daily CHWs cannot provide: • Clinical case management requiring licensure, • Childcare, chore services, or companion services, • Employment services or personal care services, • Medication delivery or transportation services, • Services duplicating other covered Medi-Cal services, • Services to non-Medi-Cal enrolled individuals (except as specified) CalAIM Community Health Workers play a crucial role in improving health outcomes and reducing disparities in California's most vulnerable populations. This position offers a unique opportunity to make a significant impact on individual and community health while working within a comprehensive, evidence-based framework that addresses the full spectrum of social determinants of health. Job Type: Full-time Expected Hours : 40 per week Pay: $21.00 - $24.00 per hour Must Reside in Hiring County Join Us in Making a Difference At Pacific Health Group, we believe in diversity and inclusion and are committed to equal opportunities for all. We strive to build a team that reflects the communities we serve. If you’re ready to arrange every detail of care, walk alongside members through their journey, and truly transform lives, apply today and become part of our mission to provide caring, comprehensive Enhanced Care Management for those who need it most. Equal Opportunity Employer Pacific Health Group is an Equal Opportunity Employer. We are committed to creating an inclusive and equitable workplace where all individuals are treated with dignity and respect. All qualified applicants will receive consideration for employment without regard to race, color, religion or creed, sex (including pregnancy, childbirth, breastfeeding, and related medical conditions), gender, gender identity or gender expression, sexual orientation, national origin or ancestry, citizenship status, physical or mental disability, medical condition (including cancer and genetic characteristics), age (40 and over), marital status, military or veteran status, genetic information, or status as a victim of domestic violence, assault, or stalking. We value diversity in all forms and encourage individuals from historically underrepresented communities to apply. Job Type: Full-time Requirements • High school diploma or equivalent; Associate's or Bachelor's degree in a related field preferred, • Prior Community Health Worker certification highly desired; willingness to obtain certification within 18 months of hire if not already certified, • Minimum of 2 years of experience in community health, social services, or related field, • Strong understanding of local community resources and social determinants of health, • Excellent interpersonal and communication skills, • Proficiency in electronic health records and basic computer applications, • Bilingual skills (English/Spanish, or other relevant languages) required Upon hire, CHWs must complete training in: • Motivational Interviewing, • Medical Terminology, • Mental Health Overview, • Medical Health Overview, • CA Child Mandated Reporter, • CA Adult and Elderly Mandated Reporter, • Culturally Competent Practices, • Dealing with Adverse Behaviors, • Home Visitations, • Group Facilitation 401(k) matching Dental insurance Health insurance Life insurance Paid time off Vision insurance