Enhanced Care Management (ECM)

Service Coordinator I: Community Health Worker (CHW)

JOB TITLE: Enhanced Care Management  Service Coordinator I: Community Health Worker

REPORTS TO: Program manager

HOURS: Full-Time

CLASSIFICATION: Non-Exempt

REQISITION #: 1785

SUMMARY: The Community Health Worker (CHW) supports individuals enrolled in the Enhanced Care Management (ECM) program who have complex medical, behavioral health, and social needs. The CHW serves as a trusted liaison between participants, healthcare providers, social service agencies, and community resources. Working in collaboration with ECM clinical staff, the CHW conducts outreach, engagement, care coordination, health education, and resource navigation to help participants access services and improve health outcomes. The CHW plays a key role in addressing social drivers of health, reducing barriers to care, and promoting participant self-management and stability.

BENEFITS AND WHAT WE OFFER:

DUTIES: Primary areas of responsibility include, but are not limited to the following: 

Participant Outreach and Engagement

• Conduct outreach to eligible or enrolled ECM participants in community settings, homes, shelters, clinics, homeless encampments, or hospitals throughout the Inland Empire.
• Build trusting relationships with participants through culturally responsive and trauma-informed engagement.
• Assist with onboarding and orientation to ECM services.
• Maintain consistent contact with participants through phone, in-person visits, and community-based engagement.

Care Coordination Support

• Work closely with ECM Case Managers, Nurses, and Behavioral Health providers to implement participant care plans.
• Support coordination between primary care, behavioral health, specialty care, and social service providers.
• Assist participants with scheduling medical, behavioral health, and social service appointments.
• Accompany participants to appointments when appropriate to support engagement and communication.

Social Determinants of Health Navigation

Assist participants in accessing services related to:

• Housing stability
• Food access
• Transportation
• Public benefits
• Employment resources
• Legal services
• Education or vocational programs

• Provide referrals and warm handoffs to community-based organizations and support services.

Health Education and Self-Management Support

• Provide education on chronic disease management, medication adherence, and preventive care.
• Reinforce health goals identified in the participant care plan.
• Support participants in understanding medical instructions and navigating healthcare systems.

Documentation and Reporting

• Document all outreach, contacts, and services provided in the program’s electronic health record (EHR) or care management system.
• Maintain accurate and timely records in accordance with ECM documentation requirements.
• Participate in case conferences and multidisciplinary care team meetings.
• Track participant progress and report barriers to care.

Community Resource Development

• Maintain knowledge of local community resources and service providers.
• Develop relationships with community-based organizations to facilitate participant access to services.
• Participate in community outreach and engagement activities.

SKILLS: Possesses ability to work both independently and as a member of a multi-disciplinary team. Must have Strong interpersonal and relationship-building skills, Cultural humility and trauma-informed approach, Motivational interviewing techniques, Knowledge of community resources and social services. Must have ability to work independently in community settings, Strong organizational and documentation skills, Basic computer skills and experience with electronic health records, Effective communication and advocacy skills.

QUALIFICATIONS: High school diploma or equivalent required.

Community Health Worker Certification required. Minimum 1–2 years experience working with vulnerable or high-need populations. Preferred experience with: Homeless or housing-insecure populations, Individuals with substance use disorders, Serious mental illness, Justice-involved individuals, High utilizers of emergency services

SUPPLEMENTAL INFORMATION: Work with people experiencing homelessness whether on the streets, in shelters or other places of habitation or services, may present inherent challenges and difficulties such as: exposure to bed bugs or other infestations, unpleasant smells or odors, individuals who may have poor hygiene or unclean homes due to homelessness, mental health symptoms, or poverty. Additionally, in working with our members, employees may encounter instances of profanity, sexually explicit or derogatory language, or verbal or physical expressions of anger and trauma. Very rarely do these situations ever escalate to physical contact, and negative or derogatory communication patterns can often be negotiated successfully. All direct care staff are provided adequate training to develop skills to deescalate crisis situations that may arise and Step Up has established procedural safeguards for all employees to mitigate (but not eliminate) these inherent risks of employment.

Please Note: This position is part of the Service Employees International Union (SEIU721) Bargaining Unit.

PHYSICAL REQUIREMENTS: While performing the duties of this job, the employee is regularly required to sit; use hands and fingers; handle or feel; reach with hands and arms; talk; and hear. The employee is frequently required to walk, balance, stoop, kneel, and/or crouch. The employee must occasionally lift and/or move up to 15 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception, and ability to adjust focus. Keyboard data entry required. Frequent community-based work, including home visits, shelters, hospitals, and community agencies. Must be able to travel locally for outreach and participant support. Combination of field work and office documentation.

Step Up utilizes the principles of trauma-informed care and mental health recovery. These principles inform our Core Values of Hope, Wellness, Voice and Choice, Respect, and Collaborative Relationships. As representatives of Step Up, employees agree to adhere to these values in their interactions with members, colleagues, supervisors, and associated community members.

STEP UP CORE VALUES

HOPE – We believe all people have the capacity for positive growth and change. We use hope to inspire and motivate ourselves, our members, our colleagues, and our community.

WELLNESS – We believe in promoting a culture that supports healthy and fulfilling lives. We use a supportive environment to foster well-being for ourselves, our members, our colleagues, and our community.

VOICE AND CHOICE – We believe in the right to choose and be heard. We use voice and choice to create meaningful outcomes and empowerment for ourselves, our members, our colleagues, and our community.

RESPECT – We believe in promoting interactions that are non-judgmental, transparent. We use respect to guide all of our words and actions with ourselves, our members, our colleagues, and our community.

COLLABORATIVE RELATIONSHIPS – We believe in forming partnerships to share resources, knowledge, and experiences. We use collaborative relationships to strengthen accomplishments for ourselves, our members, our colleagues, and our community.

Step Up provides equal employment opportunities without regard to age, ancestry, color, creed, mental or physical disability, marital status, medical condition, national origin, race, religion, sex, sexual orientation, veteran status, or any other consideration made unlawful by federal, state, or local laws.

STEP UP IS AN EQUAL OPPORTUNITY EMPLOYER