CalAIM Community Health Worker - Shasta

Position: CalAIM Community Health Worker - Shasta County

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
• 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)

Required Qualifications

• 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…