Job Description

The Community Health Worker II (CHW II) is an experienced, field-based member of the Integrated Care Team (ICT) in COPE Health Solutions’ Enhanced Care Management (ECM) program. ECM is a Medi-Cal benefit under CalAIM. It provides high-touch, person-centered care management to members with the most complex medical, behavioral health, and social needs. These include, but are not limited to, people experiencing homelessness, people with frequent avoidable emergency department or hospital visits, and people living with serious mental illness or substance use disorders.

The CHW II works mainly in person, wherever members live, seek care, or feel most comfortable. Working with minimal supervision, the CHW II is accountable for an assigned caseload of members while continuing to identify, engage, and enroll eligible members from the community as a core part of the role. The CHW II builds trust over time with members who are often hard to reach and helps members and their families follow through on their care plans by coordinating appointments and transportation, going with members to visits, supporting them after hospital or facility stays, and connecting them to housing, food, public benefits, and CalAIM Community Supports. Using motivational interviewing, harm reduction, and trauma-informed approaches, the CHW II helps members set and reach their own health goals and serves as a trusted bridge between members, their care team, and community partners.

As an experienced member of the team, the CHW II also mentors early-career CHWs. The CHW II models effective outreach and engagement in the field, coaches newer CHWs through shadowing and joint visits, and serves as a go-to peer resource for complex member situations, community resources, and ECM workflows. This mentoring role is non-supervisory; the CHW II partners with the Program Manager to support new staff and strengthen team practice.

FLSA Status

Non-Exempt

Salary Range

$29.00 - $32.00

Reports To

Program Manager

Direct Reports

None

Location

Los Angeles, CA

Norwalk, CA

Downey, CA

South Los Angeles, CA

Travel

Up to 80%

Work Type

Regular

Schedule

Full Time

Position Description:

Outreach, Engagement, and Enrollment

• Identify, locate, and engage members who are eligible for ECM, including members who are unhoused, hard to reach, or have previously declined services, through street and community outreach, home and facility visits, phone calls, and other methods members prefer.
• Explain ECM services to members and families in clear, culturally and linguistically appropriate terms, help them enroll, and serve as the primary liaison between the member and the services they need.
• Build and maintain referral relationships with shelters, clinics, hospitals, and community-based organizations to find and connect eligible members.
• Use multiple attempts and approaches to reach members, and document every outreach attempt and method used.

Assessment and Care Planning

• Meet members in the clinic, facility, home, or field to complete required assessments and screenings and identify social drivers of health affecting their health and well-being.
• Work with the care team to develop and update an individualized, person-centered, culturally and linguistically appropriate care plan for every enrolled member, and make sure members understand their plan and know how to request changes.
• Help members set personal health goals, break them into achievable steps, and track progress over time.

Care Coordination and Transitions

• Manage an assigned caseload of members with complex needs, prioritizing contact and follow-up based on each member’s acuity and changing circumstances.
• Coordinate appointments, transportation, and follow-up across primary care, specialty care, behavioral health, and social services, and accompany members to appointments when needed.
• Support members through transitions from hospitals, emergency departments, skilled nursing facilities, and other settings, including timely follow-up after discharge, to help prevent avoidable readmissions.
• Keep the Case Manager and care team informed of each member’s status, barriers, and progress, and participate actively in case reviews and interdisciplinary team meetings.
• Coordinate with other care managers, providers, and programs serving the same member to keep care connected and avoid duplication.

Health Promotion and Member Support

• Use motivational interviewing, harm reduction, and trauma-informed approaches to support behavior change, treatment adherence, and self-management of chronic conditions.
• Provide health education to members, families, and caregivers that fits their language, culture, and health literacy.
• Advocate for members with providers, agencies, and benefit programs, and help members build the skills to advocate for themselves.
• Provide emotional support and encouragement, and use de-escalation skills to respond calmly to challenging situations.
• The CHW II ensures that members’ care gaps are addressed and closed in accordance with health plan requirements.

Community Resources and Referrals

• Maintain current knowledge of Los Angeles County community resources, public benefits, and CalAIM Community Supports, such as housing navigation and medically tailored meals.
• Make referrals to community agencies, help members complete applications and enrollment forms, and follow up to confirm members received the services they need.

Mentoring and Team Support

• Mentor and coach early-career CHWs through shadowing, joint field visits, and regular check-ins, modeling effective outreach, engagement, and professional boundaries.
• Help onboard new CHWs on ECM workflows, documentation standards, field safety practices, and local community resources.
• Serve as a go-to peer resource for complex member situations, and escalate clinical, safety, or compliance concerns to the Program Manager or clinical staff.
• Share field insights and recommend improvements to workflows, tools, and training.

Documentation and Compliance

• Document all member interactions, outreach attempts, and care coordination activities in the EMR and care management systems no later than 24 hours after contact, in line with ECM and health plan requirements.
• Meet program standards for caseload, engagement, documentation quality, and timeliness.
• Represent COPE Health Solutions’ mission and maintain excellent working relationships with members, families, partners, and staff.
• Maintain HIPAA compliance and member confidentiality at all times.

Competencies:

• Sound judgment to manage a complex caseload and competing priorities independently while remaining calm and professional.
• Skill in engaging people of all ages and backgrounds, including children, teens, families, and members who are hesitant to engage.
• Proficiency in motivational interviewing, trauma-informed care, harm reduction, and de-escalation.
• Working knowledge of Medi-Cal, CalAIM, ECM, and Los Angeles County community resources.
• Ability to coach peers, give constructive feedback, and model best practices.
• Clear, respectful communication in person, by phone, and in writing, including active listening.
• Strong commitment to confidentiality given the sensitive information handled.
• Self-directed, flexible, and organized; able to work effectively in the field with minimal supervision.
• Accurate and timely documentation in a high-volume environment.
• Ability to identify and suggest improvements to workflows and systems.
• Cultural humility and the ability to maintain healthy professional boundaries.

Position Expectations:

• Be committed to the mission of COPE Health Solutions’ ECM Program.
• Behave in a professional manner and consistently demonstrate and promote respect, honesty, and dignity for members, families, and everyone on the care team.
• Model professionalism, reliability, and teamwork for early-career CHWs.
• Be committed to the constant pursuit of excellence and teamwork in improving care for members and families in the community.
• Be punctual for scheduled work, member visits, and meetings, and use time appropriately.
• Perform duties in a conscientious, cooperative manner.
• Perform the required amount of work in a timely fashion with a minimum of errors.
• Be neat and maintain a professional appearance.
• Follow program safety protocols for field and home visits.
• Maintain confidentiality and protect the program by abiding by laws and principles related to confidentiality; keep information concerning program operations, members, and employees confidential.

Qualifications:

• High school graduate or equivalent required; Associate’s degree in a health-related or related field preferred.
• Minimum two (2) years of experience as a CHW, promotor(a), care coordinator, or in a similar community-based role required.
• Experience in street and community outreach preferred (e.g., street medicine, homeless outreach, or another community-based care management program).
• Experience with ECM, Whole Person Care, Health Homes, or other Medi-Cal care management programs preferred.
• Experience training, mentoring, or precepting peers or new staff preferred.
• Successful completion of a Community Health Worker formal training program from a college, community agency, or other education institution preferred.
• Training in motivational interviewing, trauma-informed care, or harm reduction preferred.
• Written and oral fluency in English and Spanish preferred.
• Experience working in multicultural settings and knowledge of the communities served in Los Angeles County.
• Computer proficiency required; experience with an EMR or care management documentation system preferred.
• Valid California Driver’s License.
• Must have a functioning vehicle with valid insurance coverage.

Benefits:

As a firm passionate about health care, we’re deeply committed to the health and wellness of our own team members. We offer comprehensive, affordable insurance plans for our team and their families, and a host of other unique benefits, such as a yearly stipend for wellness-related activities, and a paid parental leave program. You can learn more about our benefits offerings here: https://copehealthsolutions.com/careers/

About COPE Health Solutions

COPE Health Solutions is a national tech-enabled services firm powering success for health plans and for providers in risk arrangements. Our comprehensive NCQA certified population health management platform and highly experienced team brings deep expertise, experience, proven tools, and processes to improve financial performance and quality outcomes for all types of payers and providers. CHS de-risks the roadmap to advanced value-based payment and improves quality and financial performance for providers, health plans and self-insured employers. For more information, visit https://copehealthsolutions.com/about-us/

About Enhanced Care Management

Enhanced Care Management (ECM) supports eligible Medi-Cal members with complex medical, behavioral and health-related social needs through comprehensive, person-centered coordination. Working across health care and community settings, multidisciplinary care teams—including care managers and community health workers—engage members, develop individualized care plans, connect individuals to appropriate services and coordinate with providers and community partners. The program seeks to improve access, continuity and health outcomes while addressing barriers that contribute to avoidable utilization.

To Apply:

To apply for this position or for more information about COPE Health Solutions, visit us at https://copehealthsolutions.com/careers/open-positions/