Lead Care Manager / Community Health Worker (Street Medicine)

Wellness Equity Alliance (WEA) is a novel national public health organization comprised of a multidisciplinary team of population and public health experts with backgrounds in infectious disease, public health, emergency medicine, primary care, cardiology, pediatrics, psychiatry, community health work (CHW), nursing and advanced practice pharmacy. We work nearly exclusively with underrepresented communities, fundamentally addressing health-care disparities and the social determinants of health (SDoH) that have been amplified during the COVID-19 pandemic, prioritizing the following:

• People experiencing homelessness
• Indigenous communities
• Immigrant communities
• Rural communities
• BIPoC communities
• LGBTQIA+ communities
• Justice-impacted communities

The WEA team is diverse, inclusive, and nimble enough to assemble teams of healthcare professionals within days using our proven local staff recruitment models to address population health crises and communicable disease outbreaks. The WEA team’s partnership model is collaborative and allows hospitals, health jurisdictions, state/local government agencies to provide timely care using equity-based strategies for individuals and marginalized communities.

Elevate your career to new heights with an opportunity that transcends traditional healthcare boundaries!

Wellness Equity Alliance is actively seeking compassionate and driven individuals for several pivotal roles in our groundbreaking Street Medicine program. Street Medicine is an innovative and compassionate approach to healthcare, designed to meet individuals experiencing homelessness right where they are: on the streets, in shelters, or within underserved communities. Working for WEA is more than a job; it's a calling to serve those who are most in need, directly in their environment.

Purpose of the position

Elevate your career to new heights with an opportunity that transcends traditional healthcare boundaries. Wellness Equity Alliance is actively seeking compassionate and driven professionals for several pivotal roles in our groundbreaking Street Medicine program in Riverside County. Street Medicine is an innovative and empathetic approach to healthcare, designed to meet individuals right where they are: on the streets, in shelters, or within underserved communities. This model reaches outside the walls of traditional medical facilities to deliver direct, comprehensive care to those who are homeless or experiencing housing instability. Our mobile healthcare teams bring primary care, psychiatric support, substance abuse counseling, and much more directly to the most marginalized populations.

We are looking for a Community Health Worker (CHW)/ Care Manager, that embraces our mission, which is deeply rooted in delivering equitable healthcare to underserved communities, right where they live. By joining our dedicated team, you'll not only provide critical medical services but also become a beacon of hope and change, ensuring every individual receives the compassionate care they deserve, regardless of their circumstances. Working for WEA is more than a job; it's a calling to serve those who are most in need, directly in their environment.

This Care Coordinator will serve not only as an advocate for the health needs of individuals by assisting community residents in effectively communicating with healthcare providers or social service agencies, but also as a key member of the site leadership team, assisting with logistics and program evaluation. Acting as liaison and advocate to implement programs that promote, maintain, and improve individual and overall community health. May deliver health-related preventive services such as blood pressure, glaucoma, and hearing screenings. May use the community health needs assessment to help identify areas to expand clinical services and support.This individual will also have a keen eye on data for program evaluation and understanding of team deployment and supply management.

Staff identified to be a part of this operation will be a part of an important and sustainable street medicine program aimed at serving the unhoused populations in Riverside. The most vulnerable people experiencing homelessness have likely been failed by institutions many times in their lives, and their mistrust of authorities, institutions, and individual care providers may represent an attempt at self-protection that, over time, becomes a barrier to accessing care and resources that could improve their lives.

The street medicine team will work to build trusting relationships with people who are in need of medical services, work to decrease the logistical barriers that block access to health care and provide care directly to the places where unhoused individuals live.

Community Health Workers (CHWs) are frontline public health workers who are trusted members of the community served. This trusting relationship enables CHWs to serve as a liaison between health & social services to facilitate access to services and improve the quality and cultural competence of service delivery. CHWs also build individual and community capacity by increasing health knowledge and self-sufficiency through various activities such as outreach, community education, informal counseling, social support, and advocacy.

CHWs with either lived or professional experience that aligns with and provides a connection between the CHW and the Member or population being served. This may include, but is not limited to 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 with one or more linguistic, cultural, or other groups in the community for which the CHW is providing services. Supervising Providers (the organizations employing or otherwise overseeing the CHWs with which the MCP contracts, as described below) are encouraged to work with CHWs who are familiar with and/or have experience in the geographic communities they are serving. Supervising Providers must maintain evidence of this experience.

Key Responsibilities

• Assist with daily site/program operations, such as mapping team efforts for the day or week
• Review supplies needed for each patient outreach encounter
• Evaluate program performance through key performance indicators and monitor for improvement opportunities
• Conduct outreach activities within a specific health program and/or defined patient populations with the goal of engaging multiple local businesses, schools, and other relevant organizations in our public and community health services
• Conduct telephonic and/or face-to-face outreach with patients to identify social determinants of health impacting patient's health and overall wellness
• Utilize coaching, motivational interviewing, and other evidence-based techniques to support patients in achieving their goals
• Utilize technology and digital resources to monitor ongoing care activities
• Identify barriers to achieving targeted clinical or social outcomes, and engage the care team to revise the care plan when necessary
• Documents all participant encounters; completes and submits monthly reports; maintains comprehensive electronic participant files. Documents activities, service plans, and outcomes achieved by study participants in an effective manner
• Assists participants in accessing health-related services, including but not limited to: overcoming barriers to obtaining needed medical care and /or social services
• Assists participants in utilizing community services, including scheduling appointments with health resources, and assisting with completion of applications for programs for which they may be eligible
• Works collaboratively and effectively within a team. Establishes positive, supportive relationships with participants and provides feedback to other members of the team. Builds and maintains positive working relationships with the participant, providers, nurse case managers, agency representatives, research staff, supervisors, and office staff, from diverse cultural and socio-economic backgrounds. Works to reduce cultural and socio-economic barriers between participants and institutions
• Provides health coaching, patient navigation, health education and/or health promotion for a diverse patient panel within assigned health program
• Responsible for coordinating with those individuals and/or entities to ensure a seamless experience for the member and non-duplication of services.
• Oversee provision of Enhanced Care Management (ECM) services and implementation of the care plan.
• Offer services where the member lives, seeks care, or finds most easily accessible and within
• Connect member to other social services and supports the member may need, including transportation.
• Advocate on behalf of members with health care professionals.
• Use motivational interviewing, trauma- informed care, and harm-reduction approaches.
• Coordinate with hospital staff on discharge plan.
• Accompany member to office visits, as needed and according to Health Net guidelines.
• Monitor treatment adherence (including medication).
• Provide health promotion and self- management training.
• Manage monthly and quarterly report requests from local, state and Federal entities
• Proficient in Microsoft Office Programs (Word, Excel, PowerPoint), Google Business Suite Programs (Google Docs, Sheets, GCalendar, etc)
• Collaborate with subject matter experts (SMEs) to articulate complex facets of WEA services offerings
• Assist with proposal knowledge management and retention of content for future use
• Manage interns, help supervise and develop associates base on organizational and developmental needs
• Conduct regular meetings with team members to provide guidance and leadership

Essential Skills and Qualifications:

As these positions represent some of the early roles to help build this program, we are specifically seeking out individuals with experience developing outreach programs and engaging communities and businesses to engage in meaningful health-care programs

Minimum Qualifications One of the Following

• CHW Certificate
• Violence Prevention Professional Certificate
• Work Experience Pathway

Education Experience

• High School diploma or general equivalency diploma (GED) Associates degree in a healthcare, social work, or related field (Preferred)
• Must possess either a minimum of 5 years of relevant professional experience or lived experience
• Ability to work both independently and to collaborate with teams of individuals in diverse settings, using a solution-oriented approach.
• Preference given to candidates with Community Support Worker (CSW) and/or Certified Peer Support Worker (CPSW) credentials/certifications.

Preferred Skills

• Demonstrated history of strong interpersonal skills and ability to understand and follow written/verbal instructions.
• Demonstrated knowledge of local and regional community resources.
• Demonstrated knowledge of public health programs.
• Skilled in utilizing appropriate industry standard assessment techniques.
• Demonstrated ability to provide appropriate guidance and positive customer service with utilizing a patient centered approach.
• Must possess a comprehensive knowledge of the local community based on personal lived experience or the ability to articulate the lived experience and perspective
• Preference given to bilingual Spanish speakers.
• Preference to cultural competence with LatinX communities