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 planningProvide up to 12 units (6 hours) of care per member per recommendation periodPerform health screenings and assessments using standardized tools including :Social Determinants of Health Assessment (SDOH 5-Q)PHQ-9 and PHQ-2 mental health screeningsHunger Vital Sign Screening ToolFunctional status and ADLs assessmentsConduct 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 standardsOffer coaching and goal setting to improve members' health and self-management abilitiesFacilitate health navigation services to help members access care and understand healthcare systemsConnect members to community resources necessary to promote healthAddress healthcare barriers including medical translation / interpretation and transportation servicesServe as cultural liaison and assist licensed providers in care plan developmentCommunity Outreach and Program Activities
Conduct community outreach to identify and engage high-risk, hard-to-reach individualsOrganize and participate in health screening and wellness fairsCoordinate mobile health clinics and vaccination drivesFacilitate community walks, fitness events, and wellness activitiesDistribute hygiene and wellness kits, coordinate food and nutrition drivesCanvas neighborhoods to identify social determinants of healthGroup Services and Education
Facilitate group sessions for up to 8 Medi-Cal members per billable sessionLead workshops on topics including :Domestic violence psychoeducation and safety planningTobacco cessation and effects of substance useViolence prevention and coping skillsStress management and mental health awarenessChild / adolescent immunization educationHealthy relationships and communication skillsHousing assistance and benefits navigationSupport 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 exacerbationOffer language / medical translation servicesSchedule medical appointments and provide transportation coordinationAccompany patients to appointments as neededAct as peer support and advocate as patients navigate the medical systemDocumentation and Collaboration
Maintain accurate and timely documentation of all client interactions and outcomesComplete required activity notes documenting outreach attempts and services providedUpdate Plans of Care at 6-month intervals to determine progressCollaborate with interdisciplinary care teams including RNs and licensed providersParticipate in case conferences and team meetingsEnter and maintain electronic health records and compile reportsComplete 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 preferredPrior Community Health Worker certification highly desired; willingness to obtain certification within 18 months of hire if not already certifiedMinimum of 2 years of experience in community health, social services, or related fieldStrong understanding of local community resources and social determinants of healthExcellent interpersonal and communication skillsProficiency in electronic health records and basic computer applicationsBilingual skills (English / Spanish, or other relevant languages) preferredPossess 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 InterviewingMedical TerminologyMental Health OverviewMedical Health OverviewCA Child Mandated ReporterCA Adult and Elderly Mandated ReporterCulturally Competent PracticesDealing with Adverse BehaviorsHome VisitationsGroup FacilitationStanford University Advocacy Training for CHWEssential Skills
Cultural competency and sensitivity to diverse populationsAbility to build trust and rapport with clients from various backgroundsStrong problem-solving and critical thinking skillsExcellent time management and organizational abilitiesFlexibility to work in various settings, including clients' homes and community locationsUnderstanding of chronic conditions including diabetes, hypertension, COPD, mental health disorders, and substance use disordersKnowledge of Medi-Cal policies and billing proceduresWorking Conditions
Hybrid work environment : approximately 65% field-based work, 35% remote work from homeCounty-specific assignment (Humboldt County) requiring extensive travel within the assigned county for field workRemote work includes documentation, virtual workshops, telehealth services, and administrative tasksField work includes home visits, community events, in-person workshops, and direct member servicesRegular attendance at community events, including evenings and weekends as neededDual documentation requirements using both Partnership Health Portal and Pacific Health Group systemsPublic speaking and presentation responsibilities at community eventsAbility to lift up to 25 pounds and stand for extended periods during community eventsWork in diverse community settings including homes, community centers, and outdoor venuesMaximum of 4 units (2 hours) of services per member dailyGroup facilitation requiring management of up to 8 participantsServices NOT Covered
CHWs cannot provide :
Clinical case management requiring licensureChildcare, chore services, or companion servicesEmployment services or personal care servicesMedication delivery or transportation servicesServices duplicating other covered Medi-Cal servicesServices to non-Medi-Cal enrolled individuals (except as specified)Any services requiring professional licensureImpact 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 to Friday 8 : 30AM to 5 : 00PM
Must Reside in Hiring County
Join Us in Making a Difference
At Pacific Health Group, we believe in diversity and inclusion and are committed to equal opportunities for all. We strive to build a team that reflects the communities we serve. If you’re ready to arrange every detail of care, walk alongside members through their journey, and truly transform lives, apply today and become part of our mission to provide caring, comprehensive Enhanced Care Management for those who need it most.
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 systemA formal pre-screen with our recruiting teamCompletion of a skills assessment (if applicable to the position)Participation in a final interview with hiring leadershipReceipt 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
Must reside in Humboldt County.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) matchingDental insuranceHealth insuranceLife insurancePaid time offVision insurance