Community Health Worker, Sacramento
Witt/Kieffer, Sacramento, CA, United States
EOE Statement We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status or any other characteristic protected by law.
Description
The mission of the Agency on Aging Area 4 (AAA4) is enriching the lives of older adults and people with disabilities by fostering networks of support, advocating for individual choice, collaborating with others, ensuring equity, and striving to do so with conviction.
Formed as a Joint Powers Authority to serve Nevada, Placer, Sacramento, Sierra, Sutter, Yolo, and Yuba Counties, AAA4 is a public agency with non‑profit status. Funded by monies from the Older Americans Act (OAA) and various grants, AAA4 creates, supports, and monitors a wide variety of programs for older adults and people with disabilities designed to help them maintain their health and independence. In 2023 the Agency celebrated 50 years of delivering its mission of supportive service to its communities.
AAA4 delivers Enhanced Care Management (ECM), working with managed health care plans to take a whole‑person approach that addresses both the clinical and non‑clinical needs of Medi‑Cal members to enhance health outcomes and overall well‑being. The primary goal of ECM is to reduce hospitalizations and prevent institutionalization through proactive care coordination and targeted interventions. ECM is designed to provide relatively short‑term care management to address a wide variety of complex high‑acuity health care‑related needs and barriers.
Position Overview
Under the general direction of the Enhanced Care Management Director, the Enhanced Care Management Community Health Worker (CHW) plays a vital role in supporting ECM members—including older adults and persons with disabilities—to manage chronic medical and behavioral health conditions. The CHW will serve as a trusted connector supporting care plan goals, promoting health literacy, coordinating access to social supports, and empowering members to fully engage in their care. The CHW also supports the Enhanced Care Management Lead Care Manager as a subject‑matter expert, guiding and assisting the many parties collaborating to assure timely and effective integration of various systems of support for the Medi‑Cal members served through ECM.
The CHW is required to perform regular, proactive, in‑person outreach to individuals unsheltered experiencing homelessness in non‑traditional locations (e.g., encampments, parks, shelters, facilities, underpasses, streets).
Compensation
$31.44/hour, $57,221/year
General Knowledge, Skills, and Abilities
Understanding of the normal aging process and the common needs/concerns of older adults, people with disabilities, and their caregivers.
Basic knowledge of the Older Americans Act, Title 22 of the California Code of Regulations, and the Medi‑Cal program.
Ability to communicate effectively and professionally in person, electronically, and/or by telephone.
Excellent organizational and time‑management skills.
Ability to identify concerns, assess, and problem‑solve with the general public, stakeholders, fellow employees, and volunteers to ensure satisfactory resolution of service requests.
Computer skills to maintain and report data, work with web‑based systems, use Microsoft Office 365, Microsoft Teams, Adobe Acrobat, and DocuSign.
Ability to perform, organize, and prioritize work independently in the accomplishment of a wide variety of duties.
Ability to work as a member of a team to ensure project completion within defined timelines.
Ability to establish and maintain working relationships with individuals from diverse backgrounds.
Ability to work on‑site, telecommute, in the field, and attend special events or off‑site training and conferences that may require travel, including overnight lodging.
Ability to operate with a high level of discretion and strictly adhere to confidential information policies and procedures.
Ability to be flexible and resilient in the face of competing demands and changing deadlines.
Job‑Specific Knowledge, Skills, and Abilities
Knowledge or experience in health promotion.
Knowledge of care management for chronic conditions such as diabetes.
Knowledge of the resources available in the communities served.
Knowledge of motivational interviewing, trauma‑informed care, and harm‑reduction strategies.Knowledge of relevant laws and regulations.
Ability to relate to frail, low‑income seniors from diverse cultures and ethnicities.
Ability to establish and maintain productive and collaborative working relationships.
Effective oral and written communication skills.
Ability to maintain accurate and up‑to‑date client records.
Job‑Specific Responsibilities
Conduct timely assessments for incoming and existing members assigned to ensure that all necessary health and medical information is collected to develop an actionable care plan.
Prepare and maintain comprehensive member files with all care notes, assessments, and required paperwork via the reporting system.
Attend weekly meetings with the Enhanced Care Management Director and Lead Care Manager to review progress and troubleshoot barriers.
Collaborate closely with ECM Lead Care Managers and the multidisciplinary team.
Participate in regular case conferences and planning meetings.
Implement Certified Health Navigation practices to ensure continuity and coordination of care.
Proactively contact members to schedule assessments, follow‑ups, and re‑engagement outreach.
Offer coaching, education, and support to build client confidence in managing their care.
Coordinate member transportation to medical, behavioral health, and social appointments.
Accompany members to appointments and assist with completing forms and applications.
Advocate on behalf of the members during interactions with providers and systems of care.
Connect members with health promotion materials and resources based on needs assessment.
Provide active listening, problem‑solving, and motivational interviewing to support health behaviors in a client‑centered manner.
Engage in community outreach to inform potentially eligible individuals on the availability of services, programs, and resources available through AAA4 and the network.
Abide by the Health Insurance Portability and Accountability Act (HIPAA) to ensure member confidentiality is upheld; serve as a mandated reporter for elder abuse reporting; and follow all applicable state and federal regulations.
Ensure accurate data entry, maintenance, and management of electronic client files.
Additional Requirements
Required to successfully pass a background check which includes fingerprinting.
Required to maintain the licensure/certification required of the position for the duration of employment with the agency.
Required to have a valid California driver license, regular access to a passenger vehicle, and proof of current automobile insurance if driving on behalf of the agency.
Required to be accessible electronically during work hours if working away from the office.
Employment Qualifications
Either: possession of a bachelor's degree in social work, health education, public health, or gerontology; OR 4 years of equivalent work experience; OR lived experience in community health, care coordination, peer support, or social services.
At least 1 year of experience working with individuals with behavioral health needs, co‑occurring disorders, or those experiencing homelessness.
Preferred: Community Health Worker (CHW) or Peer Support Certification.
Preferred: Bilingual and biliterate. Alliance of Information and Referral Services (AIRS) / Inform USA Certification may be required after hire.
References: three professional references from the past three years, including at least one supervisory reference.
Physical Demands
While performing the duties of this job, the employee is regularly required to sit, stand, walk, twist, and stoop; use hands and arms to grasp and reach; talk and hear. The employee must occasionally lift and/or move up to 50 pounds (NIOSH application). Required vision abilities include close vision, distance vision, peripheral vision, depth perception, and ability to adjust focus. Reasonable accommodation will be made to enable individuals with disabilities to perform the essential functions.
Note: All employees of AAA4 are required to be mandated reporters, expected to successfully pass a background check, and maintain confidentiality of all client, staff, and agency information.
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Description
The mission of the Agency on Aging Area 4 (AAA4) is enriching the lives of older adults and people with disabilities by fostering networks of support, advocating for individual choice, collaborating with others, ensuring equity, and striving to do so with conviction.
Formed as a Joint Powers Authority to serve Nevada, Placer, Sacramento, Sierra, Sutter, Yolo, and Yuba Counties, AAA4 is a public agency with non‑profit status. Funded by monies from the Older Americans Act (OAA) and various grants, AAA4 creates, supports, and monitors a wide variety of programs for older adults and people with disabilities designed to help them maintain their health and independence. In 2023 the Agency celebrated 50 years of delivering its mission of supportive service to its communities.
AAA4 delivers Enhanced Care Management (ECM), working with managed health care plans to take a whole‑person approach that addresses both the clinical and non‑clinical needs of Medi‑Cal members to enhance health outcomes and overall well‑being. The primary goal of ECM is to reduce hospitalizations and prevent institutionalization through proactive care coordination and targeted interventions. ECM is designed to provide relatively short‑term care management to address a wide variety of complex high‑acuity health care‑related needs and barriers.
Position Overview
Under the general direction of the Enhanced Care Management Director, the Enhanced Care Management Community Health Worker (CHW) plays a vital role in supporting ECM members—including older adults and persons with disabilities—to manage chronic medical and behavioral health conditions. The CHW will serve as a trusted connector supporting care plan goals, promoting health literacy, coordinating access to social supports, and empowering members to fully engage in their care. The CHW also supports the Enhanced Care Management Lead Care Manager as a subject‑matter expert, guiding and assisting the many parties collaborating to assure timely and effective integration of various systems of support for the Medi‑Cal members served through ECM.
The CHW is required to perform regular, proactive, in‑person outreach to individuals unsheltered experiencing homelessness in non‑traditional locations (e.g., encampments, parks, shelters, facilities, underpasses, streets).
Compensation
$31.44/hour, $57,221/year
General Knowledge, Skills, and Abilities
Understanding of the normal aging process and the common needs/concerns of older adults, people with disabilities, and their caregivers.
Basic knowledge of the Older Americans Act, Title 22 of the California Code of Regulations, and the Medi‑Cal program.
Ability to communicate effectively and professionally in person, electronically, and/or by telephone.
Excellent organizational and time‑management skills.
Ability to identify concerns, assess, and problem‑solve with the general public, stakeholders, fellow employees, and volunteers to ensure satisfactory resolution of service requests.
Computer skills to maintain and report data, work with web‑based systems, use Microsoft Office 365, Microsoft Teams, Adobe Acrobat, and DocuSign.
Ability to perform, organize, and prioritize work independently in the accomplishment of a wide variety of duties.
Ability to work as a member of a team to ensure project completion within defined timelines.
Ability to establish and maintain working relationships with individuals from diverse backgrounds.
Ability to work on‑site, telecommute, in the field, and attend special events or off‑site training and conferences that may require travel, including overnight lodging.
Ability to operate with a high level of discretion and strictly adhere to confidential information policies and procedures.
Ability to be flexible and resilient in the face of competing demands and changing deadlines.
Job‑Specific Knowledge, Skills, and Abilities
Knowledge or experience in health promotion.
Knowledge of care management for chronic conditions such as diabetes.
Knowledge of the resources available in the communities served.
Knowledge of motivational interviewing, trauma‑informed care, and harm‑reduction strategies.Knowledge of relevant laws and regulations.
Ability to relate to frail, low‑income seniors from diverse cultures and ethnicities.
Ability to establish and maintain productive and collaborative working relationships.
Effective oral and written communication skills.
Ability to maintain accurate and up‑to‑date client records.
Job‑Specific Responsibilities
Conduct timely assessments for incoming and existing members assigned to ensure that all necessary health and medical information is collected to develop an actionable care plan.
Prepare and maintain comprehensive member files with all care notes, assessments, and required paperwork via the reporting system.
Attend weekly meetings with the Enhanced Care Management Director and Lead Care Manager to review progress and troubleshoot barriers.
Collaborate closely with ECM Lead Care Managers and the multidisciplinary team.
Participate in regular case conferences and planning meetings.
Implement Certified Health Navigation practices to ensure continuity and coordination of care.
Proactively contact members to schedule assessments, follow‑ups, and re‑engagement outreach.
Offer coaching, education, and support to build client confidence in managing their care.
Coordinate member transportation to medical, behavioral health, and social appointments.
Accompany members to appointments and assist with completing forms and applications.
Advocate on behalf of the members during interactions with providers and systems of care.
Connect members with health promotion materials and resources based on needs assessment.
Provide active listening, problem‑solving, and motivational interviewing to support health behaviors in a client‑centered manner.
Engage in community outreach to inform potentially eligible individuals on the availability of services, programs, and resources available through AAA4 and the network.
Abide by the Health Insurance Portability and Accountability Act (HIPAA) to ensure member confidentiality is upheld; serve as a mandated reporter for elder abuse reporting; and follow all applicable state and federal regulations.
Ensure accurate data entry, maintenance, and management of electronic client files.
Additional Requirements
Required to successfully pass a background check which includes fingerprinting.
Required to maintain the licensure/certification required of the position for the duration of employment with the agency.
Required to have a valid California driver license, regular access to a passenger vehicle, and proof of current automobile insurance if driving on behalf of the agency.
Required to be accessible electronically during work hours if working away from the office.
Employment Qualifications
Either: possession of a bachelor's degree in social work, health education, public health, or gerontology; OR 4 years of equivalent work experience; OR lived experience in community health, care coordination, peer support, or social services.
At least 1 year of experience working with individuals with behavioral health needs, co‑occurring disorders, or those experiencing homelessness.
Preferred: Community Health Worker (CHW) or Peer Support Certification.
Preferred: Bilingual and biliterate. Alliance of Information and Referral Services (AIRS) / Inform USA Certification may be required after hire.
References: three professional references from the past three years, including at least one supervisory reference.
Physical Demands
While performing the duties of this job, the employee is regularly required to sit, stand, walk, twist, and stoop; use hands and arms to grasp and reach; talk and hear. The employee must occasionally lift and/or move up to 50 pounds (NIOSH application). Required vision abilities include close vision, distance vision, peripheral vision, depth perception, and ability to adjust focus. Reasonable accommodation will be made to enable individuals with disabilities to perform the essential functions.
Note: All employees of AAA4 are required to be mandated reporters, expected to successfully pass a background check, and maintain confidentiality of all client, staff, and agency information.
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