CalAIM Community Health Worker - Shasta County

Job Description

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)

Required Qualifications

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

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 (Shasta 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 through Friday 8:30AM to 5:00PM

Pay: $21.00 - $24.00 per hour

Must Reside in Hiring County

Join Us in Making a Difference

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 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

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.

Benefits

Benefits:

401(k) matching

Dental insurance

Health insurance

Life insurance

Paid time off

Vision insurance

Full-time