CalAIM Community Health Worker - Solano 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)

Essential Skills

• Cultural competency and sensitivity to diverse populations
• Ability to build trust and rapport with clients from various backgrounds
• Strong problem-solving and critical thinking skills
• Excellent time management and organizational abilities
• Flexibility to work in various settings, including clients' homes and community locations
• Understanding of chronic conditions including diabetes, hypertension, COPD, mental health disorders, and substance use disorders
• Knowledge of Medi-Cal policies and billing procedures

Working Conditions

• Hybrid work environment: approximately 65% field-based work, 35% remote work from home
• County-specific assignment (Humboldt, Shasta, or Solano County) requiring extensive travel within the assigned county for field work
• Remote work includes documentation, virtual workshops, telehealth services, and administrative tasks
• Field work includes home visits, community events, in-person workshops, and direct member services
• Regular attendance at community events, including evenings and weekends as needed
• Dual documentation requirements using both Partnership Health Portal and Pacific Health Group systems
• Public speaking and presentation responsibilities at community events
• Ability to lift up to 25 pounds and stand for extended periods during community events
• Work in diverse community settings including homes, community centers, and outdoor venues
• Maximum of 4 units (2 hours) of services per member daily
• Group facilitation requiring management of up to 8 participants

Services NOT Covered

CHWs cannot provide:

• Clinical case management requiring licensure
• Childcare, chore services, or companion services
• Employment services or personal care services
• Medication delivery or transportation services
• Services duplicating other covered Medi-Cal services
• Services to non-Medi-Cal enrolled individuals (except as specified)
• Any services requiring professional licensure

Impact and Opportunity

CalAIM Community Health Workers play a crucial role in improving health outcomes and reducing disparities in California's most vulnerable populations. This position offers a unique opportunity to make a significant impact on individual and community health while working within a comprehensive, evidence-based framework that addresses the full spectrum of social determinants of health.

Job Type: Full-time

Expected Hours : Monday to Friday 8:30AM to 5:00PM (40 hours per week)

Pay: $21.00 - $24.00 per hour

Must Reside in Hiring County

Join Us in Making a Difference

At Pacific Health Group, we believe in diversity and inclusion and are committed to equal opportunities for all. We strive to build a team that reflects the communities we serve. If you’re ready to arrange every detail of care, walk alongside members through their journey, and truly transform lives, apply today and become part of our mission to provide caring, comprehensive Enhanced Care Management for those who need it most.

Equal Opportunity Employer

Pacific Health Group is an Equal Opportunity Employer. We are committed to creating an inclusive and equitable workplace where all individuals are treated with dignity and respect. All qualified applicants will receive consideration for employment without regard to race, color, religion or creed, sex (including pregnancy, childbirth, breastfeeding, and related medical conditions), gender, gender identity or gender expression, sexual orientation, national origin or ancestry, citizenship status, physical or mental disability, medical condition (including cancer and genetic characteristics), age (40 and over), marital status, military or veteran status, genetic information, or status as a victim of domestic violence, assault, or stalking. We value diversity in all forms and encourage individuals from historically underrepresented communities to apply.

Job Type: Full-time

Job Application & Offer Disclaimer

Pacific Health Group is committed to maintaining a transparent, lawful, and secure hiring process in compliance with California labor laws and employment standards. No candidate will be offered employment without meeting the required qualifications and skillset for the position and successfully completing all steps of our recruitment process, which include:
• Submission of a completed internal application via our HRIS system
• A formal pre-screen with our recruiting team
• Completion of a skills assessment (if applicable to the position)
• Participation in a final interview with hiring leadership
• Receipt of a formal verbal offer from our authorized hiring team

⚠️ Important Notice: Any message, onboarding link, or communication that claims to represent Pacific Health Group but bypasses the steps listed above is not valid and not authorized by the company. Candidates are advised not to click on or respond to such messages. For verification, candidates may contact the Pacific Health Group Human Resources Department directly.

AI & Human Interaction (HI) in Recruitment

Pacific Health Group is committed to fairness, equity, and transparency in our hiring practices. We use AI (Artificial Intelligence) tools to help match candidate resumes against our job descriptions, focusing on qualifications, skillsets, and location.

All resumes that meet these criteria are then reviewed by HI (Human Interaction) — our recruiting and HR team. Pacific Health Group remains true to our Equal Employment Opportunity (EEO) statement, ensuring that every candidate is given fair and consistent consideration.

Requirements

• 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 already certified
• Minimum of 2 years of experience in community health, social services, or related field
• Strong understanding of local community resources and social determinants of health
• Excellent interpersonal and communication skills
• Proficiency in electronic health records and basic computer applications
• Bilingual skills (English/Spanish, or other relevant languages) preferred
• Possess a valid California Driver’s License (Class C minimum), maintain a personal, operable vehicle for daily business use, and carry current liability insurance that meets California's minimum legal requirements. All selected candidates will be required to pass a Motor Vehicle Report (MVR) background check prior to employment.

Required Training and Certifications

Upon hire, CHWs must complete training in:

• Motivational Interviewing
• Medical Terminology
• Mental Health Overview
• Medical Health Overview
• CA Child Mandated Reporter
• CA Adult and Elderly Mandated Reporter
• Culturally Competent Practices
• Dealing with Adverse Behaviors
• Home Visitations
• Group Facilitation
• Stanford University Advocacy Training for CHW

Benefits

401(k) matching

Dental insurance

Health insurance

Life insurance

Paid time off

Vision insurance