Transitional Care Services Community Health Worker II

Job Summary

The Transitional Care Services (TCS) Community Health Worker II (CHW) is responsible for promoting members’ optimal health and well-being through active engagement and helping them navigate and access health services when transitioning between care settings. The TCS CHW supports members and providers through an integrated approach inclusive of community outreach. Through assessment, collaboration, education and support, the TCS CHW helps identify and resolve members’ barriers to safe care transitions from facilities by ensuring coordination with the facility discharge staff and connecting members to their providers as well as appropriate programs and services to support their daily functioning.

Duties

Cultural Mediation Among Individuals, Communities, and Health and Social Service Systems: Educating individuals and communities about how to use health and social service systems (including understanding how systems operate). Educating systems about community perspectives and cultural norms. Building health literacy and cross-cultural communication. (5%)

Providing Culturally Appropriate Health Education and Information: Conducting health promotion and disease prevention education in a manner that matches linguistic and cultural needs of members. Providing necessary information to understand and prevent diseases and help members manage health conditions (including chronic disease). (5%)

Care Coordination, Case Management, and System Navigation: Participating in telephonic and/or in-person care coordination and case management with members, facility staff, and providers. Making post-transition referrals and providing follow-up. Coordinating transportation to services and helping address barriers to services. Documenting and tracking individual and population level data. Informing people and systems about community assets and challenges. (25%)

Providing Coaching and Social Support: Providing individual support and coaching, including how to manage their health conditions following discharge and identifying critical symptoms. Motivating and encouraging people to obtain care and other services. Supporting self-management of disease prevention and management of health conditions (including chronic disease). Planning and/or leading support and health education groups. (10%)

Advocating for Individuals and Communities: Advocating for the needs and perspectives of communities. Connecting to resources and advocating for basic needs (e.g. food and housing). Conducting policy advocacy for their communities. (5%)

Building Individual and Community Capacity: Building individual and community capacity by training with peers and among CHW groups. (5%)

Implementing Individual Assessments: Participating in design, implementation, and interpretation of individual-level assessments (e.g. Health Risk Assessments, medication reviews, home environmental and safety assessment). (10%)

Duties Continued

Conducting Outreach: Telephonic and/or in-person recruitment of individuals and families to participate in Transitional Care Services and other supports. Follow up on health and social service encounters with individuals and families, in coordination with primary care providers and facility staff. Home visiting to provide education, assessment, and social support following a care transition, if appropriate. (25%)

Perform other duties as assigned. (10%)

Education Required

High School Diploma/or High School Equivalency Certificate

Education Preferred

Experience

Required:
At least 6 months of experience as a health navigator, peer support worker, outreach worker, promotora, or working in a community setting and providing health education for chronic conditions, or equivalent.

Skills

Required:

Knowledge of community resources for Medi-Cal members.

Comfortable working with diverse populations.

Exceptional ability to connect and engage with people.

Willingness to work in various environments including 1:1 in member’s homes, hospitals, skilled nursing facilities, other clinical settings, and/ or shelters.

Excellent verbal and written communication skills.

Detail oriented, organized and possess time management skills.

Basic computer skills.

Preferred:

"Bilingual in one of LA Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese ".

Licenses/Certifications Required

Licenses/Certifications Preferred

Mental Health First Aide Certification

Required Training

Preferred:
Successful completion of a Community Health Worker formal training program from a college or other education institution is preferred.

Training in health education for chronic diseases, motivational interviewing is desirable.

Physical Requirements

Additional Information

Required:

Must have access to reliable transportation to carry out job-related essential functions.

Able to work flexible job hours.

Travel to offsite locations for work.

Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including

• Paid Time Off (PTO)
• Tuition Reimbursement
• Retirement Plans
• Medical, Dental and Vision
• Wellness Program
• Volunteer Time Off (VTO)