ECM and CSS Peer Navigator, Street Medicine; San Fernando Valley, CA)

About Healthcare in Action

At Healthcare in Action, we serve patients experiencing homelessness through an innovative “street medicine” approach by contracting with Medicare and Medicaid health plans as well as hospitals and health systems. Street medicine entails using a medically equipped van to deliver medical care directly to people experiencing homelessness in locations such as parking lots, encampments, and parks. The Peer Navigator supports members who are experiencing/ are at risk of experiencing homeless with managing their own health in San Fernando Valley, CA area.

Assist in motivating behavioral changes in patients to improve health outcomes through education, peer support, housing & resource navigation, and the relaying of shared experiences. This Peer Navigator role provides support with ECM, CSS. Enhanced Care Management (ECM) is a statewide Medi-Cal benefit under the California Advancing and Innovating Medi-Cal (CalAIM) initiative. ECM provides a whole-person approach to care for high-need Medi-Cal beneficiaries, focusing on both clinical and non-clinical needs.

The program includes a Lead Care Manager (LCM) who coordinates all healthcare-related needs and social services, advocating on behalf of the member. ECM aims to improve health and social outcomes by offering comprehensive care management and coordination services. CSS also known as CalAIM Community Supports), which provide housing navigation, tenancy sustaining, and temporary or transitional housing supports through Medi-Cal.

• Build rapport with members by communicating personal experiences with a goal of increasing the likelihood of positive behavior changes.
• Coach members to create and implement strategies that minimize risks associated with the identified common health conditions and behaviors.
• Connect members to appropriate programs to address barriers to care and to enhance compliance.
• Link members to local, county and state services/resources.
• Follow up with members and serve as a member advocate, delivering their medications and other supplies as needed.
• Coordinate and/or accompany members to medical and social services appointments that fall outside of the street medicine unit.
• Introduce tools to promote self-management & self-efficacy.
• Complete all required organization and health plan specific documentation in a timely fashion.
• Some examples include and are not limited to the following:
  • enter all patient touch points and encounter notes in HIA’s electronic health records system, member health risk, and update members’ Plan of Care after every street medicine encounter.
  • Document all required information in the care management system during phone calls with members.
  • Complete and submit a Monthly Audit Checklist assessment, individual care plans, and update member profiles in the Coordinated Entry System/HMIS.
• May occasionally drive the medically equipped van.
• Schedule encounters based on member’s acuity level using the Healthcare in Action electronic health record system.
• Work under the supervision of a Social Worker to ensure proper escalation of cases and coordination of care.
• 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 HIA’s Vision and Goals and particularly housing placement for unsheltered members.
• This position is a patient-facing role.
• Employees may be eligible for differential pay.
• Other duties as assigned.

• 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.
• Bachelor’s degree preferred plus 1+ years of work experience as defined below.
• Work Experience to include direct work…