Enhanced Care Management- Re-Entry

2 weeks ago


Woodland, United States OLE Health Full time
POSITION TITLE: Reentry Community Health Worker, ECM Program Yolo

DEPARTMENT: Behavioral Health

REPORTS TO: Behavioral Health Manager, Adult SUD Programs

LOCATION: Woodland, CA

About CommuniCare+OLE

Established in 2023, CommuniCare+OLE is the result of a union of two health centers with a deep roots in their respective communities and reputations for providing high-quality primary care to all, regardless of insurance or ability to pay: OLE Health of Napa and Solano Counties and CommuniCare Health Centers of Yolo County. Building on a legacy established by both organizations in 1972, CommuniCare+OLE is a network of federally-qualified health centers with 17 sites across Napa, Solano, and Yolo Counties. It offers comprehensive care, including medical, dental, behavioral health and substance use treatment, nutrition, optometry, pharmacy, care coordination, referrals, and enrollment assistance to more than 70,000 individuals, and no one is turned away due to lack of insurance, immigration status, or ability to pay. Many services are offered outside of its sites, including mobile health, home visiting, and community and school-based programs.

The following statements are intended to describe the major elements and requirements of the position and should not be taken as an all-inclusive list of responsibilities, duties, and skills required of individuals assigned to this job.

JOB SUMMARY: The Community Health Worker (CHW) provides regular social support, case management, and advocacy services for those recently released from incarceration who have been diagnosed with a chronic physical or mental health diagnosis, including those affected by substance use. The CHW helps folks referred navigate the local medical and mental health system and obtain the services that support stability and wellness. The CHW has lived experience and may have served time in a local/federal and/or state correctional facility, with at least 5 years since last incarceration.

EDUCATION, EXPERIENCE, TRAINING
  1. Personal lived experience in successfully navigating behavioral health services preferred
  2. High School Diploma or equivalent required.
  3. Experience working with formerly incarcerated individuals strongly preferred
  4. Experience working with individuals within health care/social service/behavioral health setting.
  5. Applicants must also pass a security background check to enter the jail facility
  6. Bilingual English/Spanish preferred


KNOWLEDGE OF WORK

1.

Demonstrated knowledge of local health care systems.

2.

Demonstrated ability to work with clients and colleagues of diverse races, ethnicities, religions, affiliations, abilities, and LGBTQIA+ identities and life experiences

3.

Ability to remain calm in crisis, emergent, and high stress situations.

4.

Able to proficiently engage and provide care to patients by way of HIPAA-compliant telehealth/video-based services and fully participate in video-based meetings and trainings

DUTIES AND RESPONSIBILITIES

1.

Utilizes personal and professional life experience to provide peer support via in-person and telehealth services in a trauma-informed and culturally humble manner.

2.

Provides patients with information about processes and procedures, including the CHW role, and assist them to successfully engage in medical, mental health, and other supportive services.

3.

Ability to attune with patients accurately and quickly, during interactions.

4.

Provides education and consultation to community, clinic and providers, and patients about the unique needs and barriers faced by those returning home from prison or jail and how service providers can effectively engage. Professionally advocates for the special needs of formerly incarcerated patients.

5.

Independently manage complex caseload.

6.

Serves as a consultant and mentor to patients, models effective coping techniques.

7.

Effectively utilize electronic health record and data collection tools to identify patients for navigation.

8.

Develop an awareness of trauma informed care principles and practices with support from supervisor and implement with all patients.

9.

Able to handle conflicts and tense patient situations with calmness, care, and sensitivity to culture, trauma, and social identities.

10.

Complete documentation within 48 hours of services in accordance with working hours, all documentation must comply with any grants, Medi-Cal, Medicare, Partnership as applicable. Participate in quality improvement efforts.

11.

Complies with established department policies and procedures, objectives, quality assurance program, safety, environmental, and patient service standards.

12.

Based on the individualized needs of each patient, CHW collaborate with the In Custody Substance Use Disorder Treatment team members on visit needs and health goals.

13.

Identifies referral needs, including those resources that address the social determinants of health.

14.

Collaborates with physicians, nurses, counselors, peer advocates, case managers, substance use disorder treatment team, Probation, patient service representatives, and other multi-disciplinary team members regarding client needs.

15.

Participates in integrated system of care, staff meetings, case review, consultation/supervision sessions and other forums as required.

16.

Conducts all work within generally accepted standards and ethical guidelines of the social work or counseling professions. Seeks out guidance from Director of Substance Use and Latinx Services and/or SUD Manager/Clinical Supervisor when questions or concerns may arise.

17.

Collects and manages confidential patient data in electronic health record and/or other platforms as determined by manager and other agency team members.

18.

Other duties as assigned

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