Lead Care Manager​/Community Health Worker; Street Medicine

Overview

Wellness Equity Alliance (WEA) is a novel national public health organization comprised of a multidisciplinary team of population and public health experts with backgrounds in infectious disease, public health, emergency medicine, primary care, cardiology, pediatrics, psychiatry, community health work (CHW), nursing, and advanced practice pharmacy. We work nearly exclusively with under‑represented communities, fundamentally addressing health‑care disparities and the social determinants of health (SDoH) that have been amplified during the COVID‑19 pandemic, prioritizing rural communities, BIPoC communities, LGBTQIA+ communities, and justice‑impacted communities.

This position is focused on conducting community outreach among unhoused populations. The Community Health Outreach Worker (CHOW) care coordinator will play a crucial role in identifying individuals with active HIV/HCV and STI cases and ensuring they are connected to appropriate care, including verifying that patients have received the correct treatment and follow‑up care. Staff selected for this role will contribute to a vital and sustainable street medicine program designed to serve unhoused communities in the Riverside County area.

• Assist with daily site/program operations, such as mapping team efforts for the day or week.
• Review supplies needed for each patient outreach encounter.
• Evaluate program performance through key performance indicators and monitor for improvement opportunities.
• Conduct outreach activities within a specific health program and/or defined patient populations with the goal of engaging multiple local businesses, schools, and other relevant organizations in our public and community health services.
• Conduct telephonic and/or face‑to‑face outreach with patients to identify social determinants of health impacting patient’s health and overall wellness.
• Utilize coaching, motivational interviewing, and other evidence‑based techniques to support patients in achieving their goals.
• Utilize technology and digital resources to monitor ongoing care activities.
• Identify barriers to achieving targeted clinical or social outcomes, and engage the care team to revise the care plan when necessary.
• Document all participant encounters; complete and submit monthly reports; maintain comprehensive electronic participant files. Document activities, service plans, and outcomes achieved by study participants in an effective manner.
• Assist participants in accessing health‑related services, including but not limited to: overcoming barriers to obtaining needed medical care and/or social services.
• Assist participants in utilizing community services, including scheduling appointments with health resources, and assisting with completion of applications for programs for which they may be eligible.
• Work collaboratively and effectively within a team. Establish positive, supportive relationships with participants and provide feedback to other members of the team. Build and maintain positive working relationships with the participant, providers, nurse case managers, agency representatives, research staff, supervisors, and office staff, from diverse cultural and socio‑economic backgrounds. Work to reduce cultural and socio‑economic barriers between participants and institutions.
• Provide health coaching, patient navigation, health education and/or health promotion for a diverse patient panel within assigned health program.
• Coordinate with individuals and/or entities to ensure a seamless experience for the member and prevent duplication of services.
• Oversee provision of Enhanced Care Management (ECM) services and implementation of the care plan.
• Offer services where the member lives, seeks care, or finds most easily accessible.
• Connect member to other social services and supports the member may need, including transportation.
• Advocate on behalf of members with health care professionals.
• Use motivational interviewing, trauma‑informed care, and harm‑reduction approaches.
• Coordinate with hospital staff on discharge plans.
• Accompany member to office visits, as needed and according to Health Net guidelines.
• Monitor treatment…