Community Health Worker Bilingual

Position Summary

The Community Health Worker (Bilingual) (CHW) for Enhanced Care Management (ECM) is an integral member of our care coordination team, providing patient-centered, whole-person care to Medicaid (Medi-Cal) beneficiaries with complex health and social needs. This position focuses on outreach, care coordination, patient navigation, advocacy, and community collaboration. The CHW will support individuals and families in accessing health and social services, overcoming barriers to care, and improving health outcomes. The position will support the implementation of ECM and CHW services.

Essential Functions

Outreach and Engagement:

1. Conduct outreach to high-risk and vulnerable populations including those with chronic illnesses, serious mental health or substance use needs, homelessness, and justice-involvement.

2. Build trusting relationships with individuals through various communication methods (phone, in-person, telehealth, field-based outreach).

3. Identify, engage, and enroll eligible members into the ECM program.

Care Coordination:

1. Serve as liaison between members, providers, and community organizations to facilitate connections to medical, behavioral health, social, housing, and legal services.

2. Provide care to clients where they are living at multiple sites throughout Sonoma, Napa and Lake counties. Some work may need to be scheduled in the evening to meet client’s needs.

3. Assess clients’ needs through a wholistic approach to inform care planning.

4. Regularly communicate with housing case management to support the participants’ housing plan.

5. Collaborate with care teams to develop and implement individualized care plans addressing health and social needs.

6. Monitor, follow up, and ensure timely access to services and resources.

7. Facilitate transitions of care.

8. Facilitate quarterly assessments of blood pressure and PHQ9 for ECM clients.

Patient Advocacy and Support

1. Educate members about available health and social services, benefits, and resources.

2. Advocate for patient needs within their care team, and assist in overcoming barriers such as transportation, and access to medications.

3. Provide informal counseling, social support, and empowerment strategies using evidence-based approaches (e.g., Motivational Interviewing).

1. Assist with maintaining Medical benefits.

4. Provide services in participant’s preferred language and arrange translation and interpretation services as indicated.

Documentation, Data and Reporting

1. Maintain accurate documentation in electronic health records (EHR) and case management databases of all care activities, case notes, assessments, and care plans.

2. Prepare and submit reports on outreach, engagement, member outcomes, and key performance indicators as assigned.

3. Track referrals and ensure up-to-date contact information for partner agencies.

4. Collect releases of information and accurately document informed consent.

5. Meet all data quality requirements of the workflow in a timely manner.

5. 6.Follow all agency procedures for data privacy, confidentiality and HIPAA compliance.

Community Collaboration

1. Establish and maintain strong working relationships with local community-based organizations, social service agencies, justice system partners, and healthcare providers.

2. Facilitate multidisciplinary meetings, case conferences, and collaborative initiatives to ensure holistic care.

3. Serve as a liaison between professional staff and the broader community

General and Administrative Responsibilities

1. Participate in agency meetings, trainings, and sponsored events.

2. Support organization of client files, office management tasks, and general office operations.

3. Perform clerical duties such as data entry, filing, and photocopying as needed.

4. Handle all client information confidentially and remain in HIPAA compliance.

5. Other duties as assigned for program efficiency.

6. Support the Mission, Vision, and Values of Catholic Charities in the performance of all essential job functions and responsibilities.

7. Ability to perform essential job functions with or without reasonable accommodations to the workplace or work processes.

Other Responsibilities

1. Work with Diocese of Santa Rosa and local parishes as appropriate and requested.

2. Perform other related duties as assigned.

Note: Catholic Charities considers this position to be a mandated reporter of child abuse and elder abuse.

Agency Culture

It is essential that all employees of Catholic Charities aspire to the following:

• A commitment to the agency’s mission, vision, and values.

• A commitment to excellence in everything we do.

• A commitment to performance and quality improvement.

• A commitment to outcomes and measured results.

• A commitment to innovation and to what is possible.

Education, Experience, and Skills Required

1. High school diploma or GED required; bachelor’s degree preferred. An additional four to six years’ experience may be considered as a substitution for the bachelor’s degree.

2. Certified Health Worker certification preferred. Required to pass CHW certification within first 90 days.

3. Bilingual skills required in English and Spanish; bicultural competence.

4. Strong interpersonal and communication skills, with the ability to build rapport with diverse populations. Familiarity with vulnerable populations including those experiencing domestic violence, substance use, mental or physical health challenges, justice-involvement, and homelessness.

5. Knowledge of local health, social service, and justice systems.

6. Ability to manage multiple tasks and prioritize in a fast-paced environment. Ability to prioritize and plan work activities to use time efficiently.

7. Resourcefulness in finding and connecting to community resources.

8. Experience working in electronic health records and database programs (e.g., Point Click Care). Demonstrated proficiency with or ability to learn Office 365 and databases; willingness to learn and apply new software and platforms as necessary for the work.

9. Experience working with Medi-Cal, managed care programs, ECM or case management initiatives.

10. Skills in Motivational Interviewing, trauma-informed care, harm reduction, and cultural humility.

11. Good organization skills, ability to produce accurate and thorough work and to monitor work for quality.

12. Dependable, able to follow instructions, respond to management direction and to use feedback to improve performance.

13. Ability to make appropriate decisions based on training and experience when faced with multiple options.

14. Ability to communicate, orally and in writing, clearly and respectfully with clients and colleagues, individually, and in group settings.

15. Ability to learn and comprehend essential job functions job tasks and carry our job functions with minimal guidance or reminders. Ability to focus and concentrate on essential job functions successfully complete essential functions with timeliness and organization.

16. Passion and enthusiasm for the mission of Catholic Charities and its clients.

17. Possess valid driver’s license; at least state required minimum of auto insurance.

18. Must pass DOJ background clearance (fingerprinting) in accordance with the Diocese of Santa Rosa’s policies, prior to start of employment.