Community Health Worker

• Provide care coordination support with a preventative health focus to CalAIM clients in conjunction with the assigned Lead Care Manager
• Maintain regular contact with assigned clients to ensure referred services are being delivered
• Complete referrals and follow-up calls for connectivity to primary care, behavioral health, home health, durable medical equipment, and other health care services
• Conduct outreach and engagement with newly referred or authorized potential clients in homes, hospitals, nursing facilities, shelters, or on the street
• Educate clients about health and mental health care systems in a culturally appropriate manner
• Conduct home, acute hospital, and skilled nursing facility visits and escort clients to appointments as clinically indicated
• Assist the Lead Care Manager with documentation for Medi-Cal waiver participation
• Identify, arrange, and monitor community services based on knowledge of Medicare, Medi-Cal, and entitlement programs
• Establish professional relationships with clients and informal support networks
• Document client-related activity in progress notes within 24–48 hours as needed
• Maintain paperwork and consistent charting for continuity of care
• Communicate with community providers, physicians, and health and social service workers
• Provide relevant client-care and program-operation information while maintaining confidentiality
• Collaborate with the interdisciplinary team to support clients living in the community
• Participate in team and program meetings, activities, and problem-solving
• Use supervision appropriately and provide updates on client activity
• Apply the Institute on Aging’s regulatory and procedural requirements
• Attend continuing education and in-service training
• Perform other reasonably related responsibilities as assigned

Community Health Worker coordinating preventive care for CalAIM clients at IOA

Community Health Worker coordinating preventive health services for CalAIM clients at IOA, an organization helping older adults and people with disabilities age in place. Connecting clients with care and community resources.

• Assess member needs in the areas of physical health, mental health, SUD, oral health, palliative care, memory care, trauma-informed care, social supports, housing, and referral and linkage to community-based services and supports
• Oversees the development of the client care plans and goal settings
• Offer services where the member resides, seeks care, or finds most easily accessible, including office-based, telehealth, or field-based services
• Connect clients to other social services and supports that are needed
• Advocate on behalf of the client with health care professionals (e.g. PCP, etc.)
• Utilize evidence-based practices, such as Motivational Interviewing, Harm Reduction, and Trauma-Informed Care principles
• Conduct outreach and engagement activities in order to facilitate linkage to the ECM program and log activity in the Client Relationship Management (CRM) system
• Evaluate client’s progress and update SMART goals
• Provide mental health promotion
• Arrange transportation (e.g., ACCESS)
• Complete all documentation, including outcome measures within the timeframes established by the individual care plans
• Maintain up-to-date patient health records in the Electronic Medical Record (EMR) system and other business systems
• Complete monthly reporting to ensure program compliance
• Attend training as assigned

Community Health Worker coordinating care and support for clients in Los Angeles County

Community Health Worker coordinating health care and support for clients in Los Angeles County. Collaborating with health care providers and social services to enhance client well-being.

Clinical Lead Care Manager providing comprehensive care in Sacramento County

Clinical Lead Care Manager providing comprehensive care for individuals with complex needs in Sacramento County. Join Vynca to make a profound difference in community health management.

• Safely drive the mobile medical clinic to pre-arranged locations within the community
• Ensure the vehicle is stocked, organized, and operational; promptly report any mechanical or equipment issues
• Set up the clinic and ensure it is properly prepared to serve patients
• Maintain accurate records of the clinic’s schedules, locations, and patient flow
• Perform pre-trip and post-trip vehicle inspections
• Oversee and maintain all aspects of clinic operations
• Greet patients, provide information about available services, and ensure they feel comfortable during their visits
• Assist with data collection to assess community health needs and improve services
• Follow all safety protocols, including proper handling of medical supplies and maintaining patient confidentiality
• Comply with health, safety, transportation, and mobile healthcare regulations
• Help maintain cleanliness and hygiene within the mobile clinic

Community Health Worker with Mission Mobile Medical driving a mobile clinic

Community Health Worker driving a mobile clinic for Mission Mobile Medical. Serving patients by providing care in various community locations and maintaining clinic operations.

• Supports Emergency Department (ED) patients with complex social, behavioral health, and substance use-related needs by providing comprehensive navigation, education, advocacy, and care coordination.
• Engages individuals with substance use disorders, applying harm reduction principles.
• Develops individualized care plans that address social needs, behavioral health concerns, and substance use-related goals in collaboration with patients and the interdisciplinary care team.
• Provides education on substance use disorders, overdose prevention, harm reduction strategies, recovery resources, and available treatment options using non-stigmatizing, evidence-informed approaches.
• Assists patients in exploring the full continuum of substance use treatment options, including outpatient services, intensive outpatient programs (IOP), residential treatment, withdrawal management, recovery housing, peer recovery support, and other community-based recovery resources.
• Facilitates timely referrals and warm handoffs to behavioral health providers, substance use treatment programs, community-based organizations, primary care providers, and specialty services.
• Conducts proactive follow-up with patients and families to promote successful linkage to treatment, encourage continued engagement, and address barriers to care.

Community Health Worker supporting complex ED patients at Cedars-Sinai.

Community Health Worker – Emergency Dept, Substance Use Navigation Focus

Community Health Worker supporting Emergency Department patients with substance use disorders at Cedars-Sinai. Providing navigation, education, advocacy, and care coordination for complex social and behavioral health needs.

• The Community Health Workers (CHW) are trusted members of their community who help address chronic conditions, preventive health care needs, and health-related social needs.
• Help patients address the social, medical, and community problems that lead to poor health.
• Support patients with health care navigation, specialty appointments/referrals, PCP appointments/establishing routine care and preventative health screenings.
• Provide culturally appropriate health information on topics related to chronic disease management and prevention.
• Receive training in Epic & Essette, DHCS requirements, trauma-informed care, motivational interviewing, and more.

Community Health Worker addressing chronic health conditions with at-risk patients

Community Health Worker at AltaMed promoting health for underserved communities in Southern California. Focused on addressing social and medical challenges impacting patients' health.

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Community Health Worker – Emergency Dept, Substance Use Navigation Focus

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