SUMMARY: As part of an interdisciplinary team, provides culturally affirmative care coordination and advocacy for patients. This includes outreach and engagement, social assessments and development of the care plan, health coaching, and linkage to social resources and healthcare.

DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: Following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.

1. Coordinates patient care activities in partnership with other members of the healthcare team, the patient, the patient's representatives, and community partners; makes referrals as appropriate.

2. Completes screening and assessments to determine patient's health and psychosocial barriers to care and wellness needs. Communicates results to healthcare team, as necessary.

3. Creates, implements and maintains care plan based on assessments.

4. Prepares case reports; documents assessment, progress notes and related information as required by Medicare, MediCal, Title 22 and other mandated regulations according to Department standards; prepares correspondence regarding patient intake or follow-up and documents in the EHR.

5. Identifies and coordinates referrals and linkage between patients and families to community resources that will assist them in achieving positive health outcomes; may contact agencies/community-based organizations on patients' behalf.

6. Educates team and allied service providers about community needs and perspectives.

7. Engages patients in home and community environments, as needed.

8. Encourages access to appropriate care, and self-management strategies through strengths-based health coaching and navigation support.

9. Mediates barriers impairing patients' ability to manage wellness and supports adherence to health improvement or treatment plan.

10. Enrolls patient in ADAP on an annual basis, or as needed (Adult Immunology Clinic)

11. Conducts HIV testing and counseling at community events as needed (Adult Immunology Clinic)

12. Coordinates repair, emission checks and service activities and maintains records of vehicle maintenance, equipment and operating expenses. Drives and operates the mobile health van to field sites (i.e. shelters, parks and meal sites) on a scheduled basis. Ensures the van is maintained/cleaned and vehicle maintenance and housekeeping logs are kept current. (Mobile Health Clinic)

13. Completes Bedside assessments in a manner that is friendly, helpful, informative and supports their participation in medical care. (required for certain positions)

14. Partners with patients during in-person warm hand-offs from medical and allied providers to provide in immediate needs assessment and initial provision of resources (required for certain positions)

15. Performs other duties as assigned.

Pay Range: $41.34 - $50.25/ Hour

The pay range for this position reflects the base pay scale for the role at Alameda Health System. Final compensation will be determined based on several factors, including but not limited to a candidate's experience, education, skills, licensure and certifications, departmental equity, applicable collective bargaining agreements, and the operational needs of the organization. Alameda Health System also offers eligible positions a generous comprehensive benefits program.

MINIMUM QUALIFICATIONS:
Required Education: High School Diploma or equivalent.

Required Experience: One year's experience in a public sector or health care service capacity, performing duties such as direct patient outreach, care coordination and linkage to community resources.

Preferred Experience: Individual history that aligns with and provides a connection to community or population being served.

Required Licenses/Certifications: Must be eligible to sign self-attestation of lived experience, as defined by California Department of Healthcare Services (DHCS): CHWs must have lived experience that aligns with and provides a connection between the CHW and the community or population being served. This may include, but is not limited to, lived experience related to incarceration, military service, pregnancy and birth, disability, foster system placement, homelessness, mental health conditions or substance use, or being a survivor of domestic or intimate partner violence or abuse and exploitation. Lived experience may also include shared race, ethnicity, sexual orientation, gender identity, language, or cultural background of one or more linguistic, cultural, or other groups in the community for which the CHW is providing services.

Preferred Licenses/Certifications: Community Health Worker certification; Emergency Technician certification. ADAP, HIV testing/Counseling certification

Required Experience: Minimum 20 hours of driving experience of large vehicles in excess of 15 ft. (Mobile Health Department)

Required Experience: Knowledge of HIV services in Alameda County, and competence in cultural differences, HIV/AIDS, minority health, sexual practices, and a demonstrated competence in working with people who use substances, Black/AA, Indigenous and other people of color, LGBT, and youth communities. (AIC Clinic)

Required Licenses/Certifications: Valid California Class C driver's license and good driving record. (certain positions only)

Any combination of education and experience that would likely provide the required knowledge, skills, and abilities as well as possession of any required licenses or certifications is qualifying.