JOB ID: 1435
The Health Homes Program (HHP) services eligible Medi-Cal beneficiaries with complex medical needs, chronic conditions, and active homelessness who may benefit from enhanced care management and coordination. The HHP coordinates the full range of physical health, behavioral health, and community-based services and supports needed by eligible beneficiaries.
The Health Home Community Health Worker (CHW) outreaches and engages potentially eligible members for the program. This is accomplished by various methods including phone calls, mailings, and community based outreach to explain the details of HHP and the benefits to the member. Once the member is enrolled, the CHW guides members with chronic illness(es) through the health care system by assisting with access challenges, developing relationships with service providers, and tracking interventions and outcomes in order to decrease avoidable emergency room visits and increase the member’s adherence to care. The CHW also functions as an advocate and primary conduit of information between and among the member and providers. Additionally, the CHW assists with linkages to permanent supportive housing, by connecting members to the Coordinated Entry System, and linkages to obtain ID/birth certificate, and increase income if member is not yet receiving benefits.
Duties and Responsibilities include:
- Conduct various methods of outreach in order to engage potential members into the program. These include telephonic, mailings, and community based means.
- Provide all necessary and indicated direct and referral services (including crisis intervention and health education) to a caseload of approximately 50-80 members and any collateral person, including their children.
- Conduct initial assessments and periodic reassessments of members’ needs, including medical, mental health, substance use, financial, housing, and support needs.
- Provide linkage to any needs as determined by periodic assessments, such as, housing and benefits.
- Develop patient-focused care plans with documented input and approval from other providers and the member in compliance with Health Home standards.
- Work with the medical staff to develop, implement, and coordinate the care plan for members with chronic illnesses, such as diabetes, asthma, congestive heart failure, hypertension, behavioral health conditions, and HIV, among other illnesses, based on the Health Home chronic disease care coordination model standards.
- Conduct home/field visits and maintain member engagement in accordance with program standards.
- Coordinate member services with internal and external service providers through regular case conferencing.
- Document member outcomes from the care plan in the case record and ensure appropriate record documentation for entire caseload.
- Assist in coordinating care with pharmacies, insurance companies, hospital discharge planning, and other providers in the network.
- Ensure that information-sharing is timely, and that it goes when and where it is needed.
- Handle appointments and non-appointment related calls from patients, as well as providers, and keep patients informed regarding scheduled appointments and ensure adherence to their medical appointments.
- Support members and providers in the medication refill process.
- Schedule and document care conferences with member’s care team to ensure that the care team members are well-informed of the required care plan implementation for each patient and to obtain necessary updates and paperwork.
- Provide patient with general information on healthy lifestyle, prevention and primary care for their chronic condition(s).
- Monitor patient satisfaction surveys/complaints and appropriately follow-up and respond to the same, as necessary.
- Use and update the directory of resources in the service area to meet basic health and human needs.
- Serve as a back-up to other Health Homes Community Health Workers or to other care team members, as needed.
- Participate in QA/QI activities and designated/required program and staff meetings, including internal and external trainings.
- Meet weekly w/program manager and HHP team, attend HHP meetings and webinars.
- Perform other duties as may be assigned.
Minimum Requirements for Employment:
- Bachelor’s degree in social work, psychology or a related health/human services field. Masters degree is preferred.
- At least 8 years experience working in homeless services preferred.
- Good oral and written communication skills, as well as good interpersonal and customer service skills and the ability to effectively work as part of a team.
- Demonstrated computer proficiency, particularly with Microsoft Office (Word, Excel) and electronic health record systems.
- Knowledge of chronic medical conditions, mental illness, substance use, and homelessness, as well as a basic understanding of public benefits and entitlements.
- Good organizational and time management skills and demonstrated ability to problem- solve using good judgment in a complex social and health services environment.
- Good working knowledge of local social and health services resources and the necessary skill to promptly acquire and effectively use such knowledge and information.
- The ability to work effectively with people from diverse cultures and socioeconomic backgrounds.
- Demonstrated Spanish language (oral and written) proficiency preferred.
- Ability to actively engage persons experiencing homelessness, behavioral health/medical/substance use concerns.
- ·Driving is an essential function of this position
- Must have Valid CA Driver's License
- Must provide proof of insurance coverage
- Must be able to qualify for PATH insurance coverage
The employee may be in contact with individuals and families in crisis who may be ill, using alcohol and drugs, and who may not be attentive to basic personal hygiene, health and safety practices. The employee may experience a number of unpleasant sensory demands associated with the member’s use of alcohol and drugs, and lack of personal hygiene. The employee must be ready to respond quickly and effectively to many types of situations, including crisis situations and potentially hostile situations. The noise level in the work environment is usually moderate in an office setting. Sometimes work may become stressful when working under pressure.
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 accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is frequently required to stand, sit, walk, stoop, talk, hear, reach above and below shoulders; use hand and finger dexterity, keyboarding and making and receiving telephone calls. The employee may be required on occasion to lift and or carry up to 20 lbs.
PATH (People Assisting The Homeless) provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, PATH complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.
How to apply:
Please visit the Path Career Site
to apply online. Search for Job #1435
to submit your application. A resume is required.