Job Description

SUMMARY:

The Community Health Worker (CHW) for Enhanced Care Management (ECM) will support and promote LACHC’s mission to follow Christ by loving and serving our neighbors through comprehensive, quality healthcare.

The CHW will be an integral part of the LACHC ECM program, which provides intensive care coordination services for high-acuity Medicaid patients. With a primary focus on the Justice-Involved population, the CHW will connect eligible patients to ECM care via outreach, peer advocacy, empowerment, support, and multidisciplinary collaboration and referrals.

ESSENTIAL DUTIES AND RESPONSIBILITIES include:

• Provide support, education, and navigational services to LACHC ECM patients with a primary focus on recently incarcerated patients experiencing chronic illness, homelessness, substance use, and/or serious mental illness.
• Facilitate relationships between patients and the health care system with the goal of addressing gaps in medical and social services care.
• Conduct outreach to individuals in the community, prison, or local jails.
• Support reentry transition planning, including coordination with correctional health, parole/probation, and community reentry programs.
• Assist patients in obtaining critical documents and benefits that support reintegration.
• Provide legal resource navigation and referrals, including expungement support when applicable.
• Facilitate connection to reentry-specific housing options to help overcome housing-related barriers.
• Support patients in navigating digital tools and technology required for healthcare and/or public benefits access.
• Conduct consistent follow-ups and field-based outreach to maintain engagement with transient or high-risk clients.
• Use lived experience to build trust and support patient motivation and hope during reintegration.
• Provide intermediary case management services to patients with the goal of formal enrollment in LACHC ECM services.
• Conduct standardized assessments of patient’s Social Determinants of Health.
• Provide health education to patients with chronic illness with evidence-based standards of care and self-management strategies.
• Document all activities of care with progress notes stored in the electronic health record.
• Make referrals for needed services and facilitate access to internal and community resources.
• Support patients and colleagues, as needed, in any activities related to ECM programming with a primary focus on the justice-involved population.
• Use effective communication skills (such as active listening and Motivational Interviewing) to build rapport with vulnerable and difficult-to-engage clients.
• Participate in multidisciplinary team meetings and collaborative efforts between social services colleagues, clinic staff, external partners, and patients.
• Complete required trainings and attend mandatory meetings pertaining to all relevant contracts, including with Managed Care Plans and the Transitions Clinic Network
• Serve as a liaison between the professional staff and the community, including developing relationships with various stakeholders in the re-entry community.
• Familiarity with and ability to work with vulnerable populations, including Domestic Violence, Substance Use, Mental and/or Physical Health Condition(s), Re-Entry, and/or Chronic Homelessness.
• Participate in and obtain certification in ongoing training topics as assigned, including, but not limited to: Motivational Interviewing, De-Escalation, Housing First, Trauma-Informed Care, Harm Reduction, Cultural Humility, Enhanced Care Management, and First Aid.
• Handle all client information confidentially and remain in HIPPA compliance.
• These duties may be modified based on the needs of the organization.
• Other duties as assigned.

QUALIFICATIONS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION and/or EXPERIENCE:

• High School Diploma or equivalent.
• CPR Certification required.
• Prior experience working with individuals experiencing homelessness, substance use, physical health conditions, mental health conditions, and/or incarceration.
• One year of case management, outreach, and/or experience working with health care systems is preferred.
• Individuals with lived experience highly encouraged to apply.

COMPUTER KNOWLEDGE:

• Experience with Electronic Health Records, Homeless Management Information System, and Microsoft Office Suite preferred.

LANGUAGE SKILLS:

• Familiarity with medical terms and operations of clinics and/or social services is useful.
• Proficiency in English required, Bi-lingual/ Bi-literal Spanish is preferred.
• Excellent verbal and written communication skills.

MATHEMATICAL SKILLS:

• Ability to calculate figures and amounts such as totals, proportions, and percentages.

REASONING ABILITY:

• Ability to solve practical problems and deal with a variety of variables in situations where only limited standardization exists.
• Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
• Ability to independently make decisions in high-pressure situations.
• Excellent organization, follow through, and ability to juggle multiple priorities in
  fast- paced environment with multiple collaborators.
• Demonstrated excellent attendance and reliability.
• Flexible and able to take initiative.

PHYSICAL DEMANDS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit and talk or hear. The employee frequently is required to use hands to finger, handle, or feel. The employee is occasionally required to stand; walk; reach with hands and arms; climb or balance; and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision and ability to adjust focus. The employee must be able to conduct field-based community outreach as needed.

WORK ENVIRONMENT:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee will be exposed to carriers of contagious diseases. The employee may have to deal with irate and irrational clients who may or may not be under the influence of mind-altering substances such as cocaine, marijuana, alcohol, etc.

The employee will have access to patient charts which contain confidential information about medical conditions and other personal matters. The employee must display a commitment to always maintaining patient confidentiality.

WORK STATUS:

Full-time, Regular, non-exempt position with Medical, Dental, Vision and 403B Retirement Plan with employer match.

Los Angeles Christian Health Centers opened in 1995 with a handful of staff but a big vision to render hope and healing through healthcare to the thousands of homeless and low-income residents living in Los Angeles County. Today, 120 staff members serve the County’s most vulnerable populations from our two full-time health centers in Skid Row and Boyle Heights. We also provide comprehensive medical care at our 10 part-time satellite clinics hosted by our community partners throughout Downtown Los Angeles and Watts.

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