CalAIM Community Health Worker - Solano

4 weeks ago Be among the first 25 applicants

This range is provided by Pacific Health Group. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

$21.00/yr - $24.00/yr

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.

• 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

• 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
  • Conduct in-home environmental trigger assessments for asthma patients (up to 2 visits annually)
• Health Education and Navigation
  • 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
• Community Outreach and Program Activities
  • 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
• Group Services and Education
  • 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
• Support and Advocacy Services
  • 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
• Documentation and Collaboration
  • 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)
• Essential Skills
  • 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
  • Knowledge of Medi‑Cal policies and billing procedures
• Working Conditions
  • Hybrid work…