Location : Candidates for this position must reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties).
Description :
The D-SNP Community Health Worker (CHW) is a non-licensed, non-clinical member of the Care Management team who engages dual-eligible members and caregivers by phone, in the community, and in the home where applicable to build trust and remove practical barriers to care.
What You Will Do :
Member and Caregiver Engagement & Support :
- Outreach to introduce the program, confirm consent, and explain CHW support and next steps.
- Conduct home or community visits as applicable following safety procedures; observe environmental needs and report findings.
- Manage an outreach / case list, prioritize by need, and meet required turnaround times and productivity standards.
- Answer inbound calls and return messages; route issues to appropriate team members when outside CHW scope.
- Coordinate interpreter / language services and ensure materials match member language preferences.
- Participate in team huddles / ICT updates by sharing brief status and linkage progress (does not lead care planning).
- Maintain HIPAA / confidentiality and professional boundaries; obtain / track consents or releases as required.
Coordination of Services and Community Resource Navigation :
Schedule / reschedule medical, behavioral health, and LTSS appointments; place reminder calls / texts.Coordinate transportation (non-emergent) and troubleshoot logistics barriers (e.g., directions, access).Connect members to community resources / benefits (e.g., IHSS, HCBS / CBAS, FQHCs, food and housing programs, utilities assistance); assist with referrals and applications.Facilitate warm handoffs to providers, community agencies, and internal CM team members.Support transitions of care (e.g., post-discharge check-ins, follow-up appointment reminders, pharmacy pick-ups).Keep resource directories current and share tailored resource lists (mail / email / text) with members and caregivers.Social Needs Screening and Health Education :
Conduct brief social needs (SDOH) screenings with members / caregivers (not formal psychosocial assessments).Support HRA outreach (reminders, scheduling, and assistance as allowed by protocol).Provide basic health education and teach-back to reinforce care-plan tasks and self-management (no counseling / clinical instruction).Documentation, Communication, and Escalation :
Document all contacts, referrals, and outcomes accurately and on time in the care-management system; close the loop on open items.Identify barriers, risks, or safety concerns and escalate promptly to the RN Care Manager or Social Worker per protocol.Other duties as assigned.You Will Be Successful If :
Builds trust and rapport with members and caregivers using plain language and culturally sensitive communication practices.Demonstrates clear, professional verbal and written communication; uses teach-back techniques to ensure member understanding.Conducts brief, non-clinical screenings for needs such as housing, food, transportation, utilities, and social support; identifies when issues require escalation.Understands and connects members to local programs and services (e.g., IHSS, HCBS / CBAS, FQHCs, public health, housing, and food support).Assists with executing care-plan tasks and health risk assessment (HRA) outreach in alignment with established protocols; does not create or modify care plans.Coordinates appointments, reminders, and transportation; facilitates smooth transitions through warm handoffs to healthcare providers and community partners.Supports post-discharge activities such as follow-up appointments and medication pick-ups to minimize gaps in care.Maintains timely, organized, and accurate documentation of member interactions, referrals, and outcomes in the care management system.Upholds HIPAA and privacy standards, consent and release protocols, and maintains professional boundaries and ethical conduct.Effectively manages outreach and case lists; meets productivity and turnaround expectations while following standardized workflows and scripts.Resolves logistical and access-related issues within scope; escalates clinical, safety, or complex psychosocial concerns to appropriate care team members.Works closely with RN Care Managers, Social Workers, Member Services, and community partners; consistently reliable and responsive.Comfortable conducting community and home visits; recognizes and reports environmental risks and unmet needs appropriately.Delivers simple, accurate health information and encourages self-management behaviors within scope (not providing clinical advice or counseling).Utilizes phones, computers, call systems, and standard office software for outreach, scheduling, and data entry.Uses interpreter services as needed; bilingual or multilingual abilities are highly valued.What You Will Bring :
High school diploma or GED.CHW training / certificate or willingness to complete approved CHW training within 2 years of hire.2-3 years in a community-facing role (e.g., community outreach, patient services, care / navigation support, promotor(s), member services, housing / food assistance, or similar).Experience working with vulnerable populations (e.g., seniors, people with disabilities, behavioral health needs, homelessness, or significant social needs).Familiarity with Medi-Cal / Medicare basics and community benefits / resources (IHSS, HCBS / CBAS, housing / food supports, transportation).Bilingual in Spanish preferred.About Impresiv Health :
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.
That s Impresiv!