AGENCY DESCRIPTION:  

Instituto Familiar de la Raza, Inc. is a multi-service community health and social service agency with an emphasis on serving the Chicano/Latino/Indígena community in San Francisco with a special focus on the diverse needs of the Mission District. Services include a wide range of mental health, HIV-related services, and social services, including health promotion, education, prevention, early intervention, case management, psychological and psychiatric interventions, and cultural/social and spiritual re-enforcement. The agency serves children, youth, adults, and families. It has a rich history of working collaboratively with other agencies to meet the needs of the Chicano/Latino/Indígena community and other cultural/racial communities in San Francisco.

PROGRAM/POSITION DESCRIPTION:  

CalAIM Enhanced Care Management (ECM) is a patient-centered program under California’s CalAIM (California Advancing and Innovating Medi-Cal) initiative, designed to provide comprehensive, whole-person care to Medi-Cal beneficiaries with complex health and social needs. The ECM program focuses on high-risk populations, such as individuals with multiple chronic conditions, serious mental health and substance use needs, or those experiencing homelessness, by offering intensive, coordinated care management and other services. Through a team-based approach, ECM program staff work closely with members, healthcare providers, and community organizations to address the medical, behavioral, and social determinants of health, connecting members to vital resources such as housing support, behavioral health services, and social services. The goal of ECM is to improve health outcomes, reduce health disparities, and promote better health and stability for vulnerable populations in our community.

The Community Health Worker plays a critical role in supporting the CalAIM program by serving as a key point of contact for members and community partners. This position is responsible for conducting outreach, managing care coordination, and referring Medi-Cal members to receive tailored, patient-centered care through the CalAIM initiative. The Community Health Worker will help facilitate access to health services, address social determinants of health, and support members in navigating the healthcare system.

Essential Job Duties include but are not limited to the following:  

Outreach and Engagement

• Conduct outreach to Medi-Cal members, focusing on high-risk populations, including individuals with serious mental health, substance use and other needs.
• Build relationships with members and engage them in the ECM program through various communication methods (e.g., phone, in-person, telehealth).
• Assist in the identification and enrollment of eligible members for the ECM program.

Care Coordination

• Act as a liaison between members, providers, and community organizations to facilitate connection to services
• Collaborate with the Care Team to develop and implement individualized care plans that address members' health and social needs.
• Coordinate referrals for behavioral health, social services, housing support, and other community resources.
• Monitor and follow up on the status of referrals and ensure services are accessible and provided in a timely manner.

Documentation and Reporting

• Maintain accurate and up-to-date documentation in the care management system, including progress notes, assessments, and care plans.
• Prepare regular reports on outreach activities, member outcomes, and barriers to engagement.
• Track and report on key performance indicators (KPIs) and quality measures for the CalAIM program.

Member Advocacy and Support

• Educate members on available health and social services and advocate for their needs.
• Provide ongoing support and assist members in overcoming barriers to care, such as transportation, housing instability, and access to medications.
• Facilitate transitions of care (e.g., from hospital to home) and ensure members receive appropriate follow-up services.

Community Collaboration

• Establish and maintain strong working relationships with community-based organizations, social service agencies, and healthcare providers.
• Participate in multidisciplinary meetings and case conferences to ensure a holistic approach to care.

All other relevant duties as assigned

REQUIRED SKILLS:

• Bilingual skills required in English and Spanish
• Bicultural competence.
• Strong interpersonal and communication skills.
• Ability to build rapport with diverse populations.
• Knowledge of local health and social service systems.
• Ability to manage multiple tasks and prioritize in a fast-paced environment.
• Good communication skills and ability to be resourceful in finding connections and resources.

PREFERRED SKILLS:

• Proficiency in electronic health records (EHR).
• Experience working with Medi-Cal, managed care programs, or CalAIM initiatives.
• Care Management or Case Management certification.
• Knowledge of database programs such as EPIC.

EDUCATION, CERTIFICATION AND LICENSES

• High School diploma or GED

CONDITIONS OF CONTINUED EMPLOYMENT

• Conduct annual Tuberculosis Test
• Must pass Department of Justice Fingerprint screening
• Must provide proof of COVID-19 Vaccination upon hire (Reasonable Accommodation Requests will be considered)

PHYSICAL DEMANDS:  

The physical demands described here represent what an employee encounters while performing the essential functions of this job. Reasonable accommodations can be made to enable individuals with disabilities to perform essential functions.  

• General ability to communicate effectively in person or via telephone in a manner that can be understood by those with whom the person is speaking too, including a diverse population  
• General alertness to address emergency or potentially dangerous situations   
• Requires physical ability to remain seated at a desk for long periods of time when needed 
• Basic manual dexterity to operate work processing equipment with skill, speed, and accuracy  
• Must be able to view computer for long periods of time  
• Ability to use public and/or private modes of transportation; duties are office-based, but travel to various  offsite venues is required  
• Activities that occur infrequently are: bending, squatting, crouching, kneeling, twisting, reaching straight, above  or below shoulders  
• On occasion, must lift up to 35 LBS 

COMPENSATION AND BENEFITS²  

The salary range for this position is $25.08 to $27.72 hourly based on qualifications and experience. This is a full-time, non-exempt position at 35 hours a week with full benefits. The Community Health Worker will report directly to the ECM Program Manager.

All full-time positions at IFR are 35 hours per week and are eligible to participate in medical health benefit plans including dental, vision, 403(b) plan, earn vacation, sick leave, fourteen paid holidays, two paid days off (birthday and hire anniversary date) and ongoing learning opportunities.

TO APPLY:

Interested applicants should send an email to [email protected] addressed to the Human Resources Department, Instituto Familiar de la Raza, Inc. with “Community Health Worker – Enhanced Care Management Position” in the subject line and include the following files as attachments:

• A cover letter, indicating why you wish to join the Enhanced Care Management team and what makes you the ideal candidate.
• An up-to-date resume

Please note: a resume without a cover letter will not be considered.

Instituto Familiar de la Raza, Inc. (IFR) is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. For more information about your rights as an applicant, please see the U.S. Equal Employment Opportunity Commission poster.

For the complete nondiscrimination and affirmative action policy, please see the Civil Rights Department State of California's Discrimination, Harassment, and Affirmative Action in the Workplace policy.

² Please note that IFR reserves the right to change its benefits and contributions at any time at its sole discretion.