Community Health Worker, Enhanced Care Management (PSH)

Client Engagement & Support 

• Build rapport and maintain trusting relationships with ECM clients living in PSH settings

• Conduct outreach, home visits, and wellness checks to support engagement in ECM and related services

• Assist clients in identifying personal health and life goals and developing action plans to achieve them

• Provide culturally responsive education on health topics, medication adherence, and chronic disease management

Care Coordination 

• Collaborate with the ECM interdisciplinary team, including Care Managers, Behavioral Health Clinicians, Substance Use Navigators, and Housing Case Managers to coordinate care and services

• Support care transitions, such as hospital discharges, changes in medical conditions and in housing, or benefits

• Help clients navigate healthcare systems, schedule appointments, arrange transportation, and access benefits or entitlements

• Document client encounters and progress in alignment with ECM and Cardea Health standards

System Navigation & Advocacy 

• Advocate for client needs within healthcare, housing, and social service systems

• Identify barriers to care and collaborate with the ECM team to problem-solve and reduce those barriers

• Maintain knowledge of community-based services and resources to connect clients effectively

Program Implementation & Collaboration 

• Participate in team case conferences, quality improvement activities, and ECM data tracking

• Work collaboratively with PSH site staff to promote integrated and coordinated care delivery

• Uphold Cardea Health’s mission, values, and trauma-informed, harm reduction, and person-centered principles in all interactions

Minimum Required Skills & Qualifications: 

• Experience providing direct support to individuals experiencing homelessness, behavioral health conditions, or chronic illness

• Knowledge of harm reduction, motivational interviewing, and trauma-informed care practices

• Strong interpersonal skills and the ability to build rapport with diverse populations

• Familiarity with community-based resources, public benefits, and housing systems

• Valid California driver’s license or ability to travel to various PSH sites as needed

• High School Diploma or equivalent 

• Must have personal, reliable transportation to and from shifts 

• Must be 18 years of age or older 

• Self-directed and able to work with minimal supervision 

• Must be detail oriented and highly organized 

• Must be COVID vaccinated or willing to be vaccinated

Preferred Skills & Qualifications:  

• Certification as a Community Health Worker or Peer Specialist

• Bilingual in English and Spanish or another language commonly spoken in the community

• Experience working within Medi-Cal ECM, CalAIM, or managed care coordination programs

Physical Requirements:  

• Occasional sitting or stationary work 

• Frequent standing, walking, kneeling, stooping, and ascending stairs 

• Occasional lifting and carrying up to 20 lbs 

• Frequent pushing and pulling 

• Frequent reaching high, low, and level

Work Environment: 

• Position is primarily field-based with time spent in PSH sites and community settings

• Occasional evening or weekend work may be required

• Must be able to navigate stairs and varied building conditions typical of PSH environments

Benefits: 

Employees in this role may be eligible for a range of benefits, including: 

• Employer-supported medical  

• Access to dental and vision insurance  

• Paid vacation and sick time

• Retirement plan (401k) participation with a company match  

• Commuter benefits

• Long Term Disability  

• Life Insurance 

• Eligibility for certain benefits may vary based on hours worked per week and length of employment  

• Specific details are provided in the benefits guide and are subject to change 

Cardea Health is an Equal Opportunity Employer 

Cardea Health is committed to diversity in the workplace. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, age, gender identity or gender expression, genetic information, marital status, national origin, disability, citizenship or veteran status. We will consider qualified candidates with criminal histories in a manner consistent with the requirements of the state of California and San Francisco Fair Chance Ordinance. 

This job description is not designed to contain a comprehensive list of activities, duties, or responsibilities for this role. Activities, duties, or responsibilities may change, or a new job description may be assigned at any time with or without notice.