Bilingual Spanish Community Health Worker

Position: Bilingual Spanish Community Health Worker )
** The Job
** Enhance frail seniors' ability to age in place, manage their health, navigate the health care system, and live independently by providing person-centered care in accordance with ECM requirements. This individual will act as an integral part of the care team by working directly with members telephonically and in-person to implement plans of care, advocate on behalf of the member and provide member-centric interventions.

** You Will
*** Collaborate in conducting general assessments to identify chronic conditions and psychosocial challenges affecting independent living. Perform assessments for Medi-Cal/Medicare dual-eligible members referred to Complex Care Management for Long-Term Services and Supports (LTSS) and assist the Registered Nurse in determining Nursing Facility Level of Care.
* Support member well-being through observation, positive communication, and motivational interviewing. Conduct face-to-face or phone visits to address care barriers, ensure engagement in primary and preventative care, and support individualized care plan implementation.
* Provides general care coordination and empower members and their families in managing chronic conditions through coaching, education, healthcare navigation, advocacy, accompaniment to appointments and referrals to community, county, and state resources.
* Perform Enhanced Care Management (ECM) activities related to specific Populations of Focus (POF):
Individuals Experiencing Homelessness, Individuals At Risk for Avoidable Hospital Or ED Utilization, Adults Living In the Community At Risk of LTC Institutionalization, Adult Nursing Facility Residents Transitioning Back to the Community.
* Implement personalized care plans tailored to the medical and social needs of high-risk members, incorporating realistic health goals supporting members inherent wishes.
* Actively participates in interdisciplinary planning and case conference meetings to ensure person-centered care and to ensure member receives support following discharge from an inpatient or institutional setting.
* Demonstrates strong organizational, follow-through, and engagement skills to achieve positive member outcomes. Adheres to SNP policies and ensures timely, accurate documentation of care plans, service plans, and progress notes within established time frames.
* Network and build relationships with community business organizations like senior and wellness centers, housing outreach events, shelters, landlords, legal aid providers, etc.
* Utilizes department desktop procedures, workflows, job aids and training material. Identifies barriers to work processes and brings to the attention of the supervisor/manager.
* Performs work under direct supervision. Handles basic issues and problems and refers more complex issues to higher-level staff. Possesses beginning-to-working knowledge of subject matter.
* We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.
* Actively support the achievement of SCAN’s Vision and Goals.
* Other duties as assigned.  
** Your Qualifications
*** High School Diploma or equivalent experience
* Community Health Worker Certificate strongly preferred
* BILINGUAL required in English/Spanish. (Test will be administered to assess proficiency if applicable.)
* Travel 50+% of the time in the assigned area
- Must have a valid driver’s license, automobile insurance and reliable transportation
* 1+ years of Community Engagement Experience.
* Experience with managed care, healthcare environment, lived experience or case management strongly preferred.
* 1+ years working with seniors, conducting home visits, and working remotely strongly preferred.
* Technical expertise - Bssic technical skills for functional area
* Problem…