Community Health Worker (Enhanced Care Management)

• In collaboration with the LACHC Field Medicine team, conduct in-person outreach in the Skid Row community and Interim Housing sites to link eligible patients to ECM services.
• Provide support, education, and navigational services to LACHC ECM-eligible patients experiencing chronic illness, homelessness, substance use, and/or serious mental illness. 
• Facilitate relationships between patients and the health care system with the goal of addressing gaps in medical and social services care. 
• Conduct outreach to community partner agencies, as assigned, to ensure linkages to LACHC ECM services.  
• Support reentry transition planning for ECM Justice-Involved patients, including coordination with correctional health, parole/probation, and community reentry programs.
• Assist patients in obtaining critical documents and benefits that support reintegration.
• Provide legal resource navigation and referrals, including expungement support when applicable.
• Facilitate connection to housing navigation options to help overcome housing-related barriers.
• Support patients in navigating digital tools and technology required for healthcare and/or public benefits access. 
• Conduct consistent follow-ups and field-based outreach to maintain engagement with transient or high-risk clients.
• Use lived experience to build trust and support patient motivation and hope during reintegration.
• Provide intermediary case management services to patients with the goal of formal enrollment in LACHC ECM services. 
• Conduct standardized assessments of patient’s Social Determinants of Health.
• Provide health education to patients with chronic illness with evidence-based standards of care and self-management strategies. 
• Document all activities of care with progress notes stored in the electronic health record.
• Make referrals for needed services and facilitate access to internal and community resources.
• Support patients and colleagues, as needed, in any activities related to ECM programming with a primary focus on the justice-involved population and/or field medicine patients. 
• Use effective communication skills (such as active listening and Motivational Interviewing) to build rapport with vulnerable and difficult-to-engage clients.
• Participate in multidisciplinary team meetings and collaborative efforts between social services colleagues, clinic staff, external partners, and patients.
• Complete required trainings and attend mandatory meetings.
• Serve as a liaison between professional staff and the community, including developing relationships with various stakeholders in the re-entry community.
• Familiarity with and ability to work with vulnerable populations, including Domestic Violence, Substance Use, Mental and/or Physical Health Condition(s), Re-Entry, and/or Chronic Homelessness. 
• Participate in and obtain certification in ongoing training topics as assigned, including, but not limited to: Motivational Interviewing, De-Escalation, Housing First, Trauma-Informed Care, Harm Reduction, Cultural Humility, Enhanced Care Management, and First Aid.
• Handle all client information confidentially and remain in HIPPA compliance.
• These duties may be modified based on the needs of the organization.
• Other duties as assigned. 

• High School Diploma or equivalent.
• CPR Certification required.
• Prior experience working with individuals experiencing homelessness, substance use, physical health conditions, mental health conditions, and/or incarceration. 
• One year of case management, outreach, and/or experience working with health care systems is preferred.
• Individuals with lived experience of incarceration and/or homelessness encouraged to apply.

• Experience with Electronic Health Records, Homeless Management Information System, and Microsoft Office Suite preferred. 

• Familiarity with medical terms and operations of clinics and/or social services is useful.
• Proficiency in English required, Bi-lingual/ Bi-literal Spanish is preferred.
• Excellent verbal and written communication skills.

• Ability to calculate figures and amounts such as totals, proportions, and percentages.

• Ability to solve practical problems and deal with a variety of variables in situations where only limited standardization exists. 
• Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
• Ability to independently make decisions in high-pressure situations.
• Excellent organization, follow through, and ability to juggle multiple priorities in fast- paced environment with multiple collaborators.
• Demonstrated excellent attendance and reliability.
• Flexible and able to take initiative. 

Los Angeles Christian Health Centers opened in 1995 with a handful of staff but a big vision to render hope and healing through healthcare to the thousands of homeless and low-income residents living in Los Angeles County. Today, 120 staff members serve the County’s most vulnerable populations from our two full-time health centers in Skid Row and Boyle Heights. We also provide comprehensive medical care at our 10 part-time satellite clinics hosted by our community partners throughout Downtown Los Angeles and Watts.