Pediatric Community Health Worker - ONSITE & IN THE FIELD

General Description
The Pediatric Community Health Worker (CHW) will provide care coordination, health education and navigation, and resource referral services that are medically necessary for HPSM’s infant and toddler members, as well as family members. This includes connecting members to primary care providers, addressing social determinants of health (SDOH), and providing or coordinating access to other needed services to improve members’ physical and mental health. The CHW will act as a liaison collaborating directly with primary care offices, social services, and the community to facilitate access to services and improve the quality, health equity, and cultural competence of service delivery. The CHW will play a critical role in improving the health and well-being of members by using their knowledge of the member’s community and common lived experiences. This is an in-person, field-based position that requires employees to travel from the HPSM office to member’s homes and other locations (e.g., medical office, county offices, etc.) mostly within San Mateo County.
Qualifications
The following represents the typical way to achieve the necessary skills, knowledge and ability to qualify for this position:
Education and Experience

• CHW certification or experience pathway (at least 2,000 working hours as CHW or case manager). If experience pathway, candidate must obtain CHW certification within eighteen (18) months of hire.
• Associate or bachelor’s degree in justice or social services (e.g. public health, psychology, social work, sociology) with at least 1 year providing direct services to a Medi-Cal population, families, or in a field-based setting required.
• Must have relevant lived experience that connects the CHW to the served population. This includes, but is not limited to, incarceration, military service, pregnancy, disability, foster care, homelessness, mental health conditions, substance use disorders or surviving domestic or intimate partner violence and exploitation. Lived experience may encompass shared race, ethnicity, sexual orientation, gender identity, language, or cultural background with one or more groups in the community for which the CHW is providing services.
• A valid CHW certificate must include completion of a curriculum that attests to demonstrated skills and/or practical training in the following areas: communication, interpersonal and relationship building, service coordination and navigation, capacity building, advocacy, education and facilitation, individual and community assessment, professional skills and conduct, outreach, evaluation and research, and basic knowledge in public health principles and social drivers of health (SDOH), as determined by the Supervising Provider. Certificate programs must also include field experience as a requirement.

Skills

• Bilingual fluency in Spanish is required to effectively communicate with our diverse member population.
• Intermediate proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, and PowerPoint and use of computers.
• Advanced motivational interviewing skills.

Knowledge

• Extensive knowledge of Medi-Cal benefits and the managed care CHW benefit.
• Working knowledge of San Mateo County or other community resources available to Medi-Cal members.
• Extensive knowledge of Personal Health Information (PHI) privacy and security requirements and best practices for maintaining confidentiality of health information.

Abilities

• Ability to synthesize important information shared during in-person or virtual visits into a standardized note format.
• Ability to navigate complex systems of care and simplify steps for referrals and follow-ups.
• Ability to encourage member autonomy via the teach back method to gauge understanding.

Licensure/Certifications

• A valid CHW certification is required or the ability to obtain CHW certification within 18 months of employment is required.

Driving

• Verifiable, clean DMV record and ability to travel to various locations throughout California up to 85% of the time.
• Must have reliable and insured transportation and use own vehicle for job-related duties.

Duties & Responsibilities
Essential Functions
Case Management

• Maintain a caseload of members and their families with varying needs.
• Function as a liaison between members and providers, coordinating services among multiple providers and community agencies on behalf of member’s and their families.
• Provide Health Education and outreach to members, promoting wellness and prevention. This may include providing information, instruction, coaching and goal setting to improve a member’s physical and mental health, address barriers and/or ability to self-manage health conditions.
• Function as a health navigator providing members with information, training, referrals, advocacy on their behalf, or other assistance to help members receive services related to perinatal care, sexual and reproductive health, environmental and climate-sensitive health issues, oral health, aging, injury, domestic violence and other violence prevention services.

Care Plan Implementation

• Administer Mini Risk assessments and other assessment tools to members at regular intervals.
• Assist members in identifying their goals (health, behavioral, social, etc.) and supporting them in achieving these goals.
• Independently conduct in-person/in-home/in-facility assessments for those enrolled in the Baby Bonus program and assess needs related to: physical or behavioral health, Activities of Daily Living (ADLs) / Instrumental Activities of Daily Living (IADLs), Safety, Behavioral Health, SDOH and other needs for community resources or services.
• Assist members in identifying their strengths and barriers to successfully meet their care plan goals, while focusing on member-centric health choices.
• Collaborate with community providers/partners to ensure services are coordinated effectively.

Community Liaison

• Complete follow-up visits either in person or via telecommunication as outlined in the visit guide.
• Conduct in-home/in-facility visits and assess any safety concerns; provide follow-ups to resources and consult with supervisor, as appropriate.
• Facilitate interdisciplinary communication and hand offs to other team members.
• Provide members and families with information about HPSM benefits, programs, and processes, staying up to date on this information as there are changes.

Data & Reporting

• Maintain required and complete documentation within two (2) business days for all activities in the plan’s care management system, MHK, or other appropriate HPSM systems.
• Maintain required fiduciary code tracking in shared spreadsheet within 1 business day.
• Track high acuity members on the caseload, create a summary of the case, and report to the team on a weekly basis.
• Add new member data into MHK system, and other systems upon enrollment and disenrollment.

Secondary Functions

• Maintain a valid CHW certification.
• Maintain a valid CA driver’s license and a satisfactory driving record.
• Maintain reliable and insured transportation.
• Maintain language fluency in the required language(s) indicated above.
• Act as an SME to colleagues and partners regarding community resources and programs.
• Participate in continuous quality improvement activities.
• Perform other duties as assigned.