CalAIM Community Health Worker - Shasta

CalAIM Community Health Worker – Shasta County

Base pay range: $21.00/yr - $24.00/yr

At Pacific Health Group, we are dedicated to improving health outcomes by addressing social determinants of health and coordinating comprehensive community-based services, particularly through our CalAIM programs. Join our team and make a difference.

• 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

• 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
• Conduct in-home environmental trigger assessments for asthma patients (up to 2 visits annually)

• 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
• Serve as cultural liaison and assist licensed providers in care plan development

• 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
• Canvas neighborhoods to identify social determinants of health

• 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
• Housing assistance and benefits navigation

• 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
• Act as peer support and advocate as patients navigate the medical system

• 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
• Complete billing using appropriate CPT codes (98960, 98961, 98962, T1028)

• High school diploma or equivalent;
  Associate's or…