D-SNP Community Health Worker

Central Coast Hourly Range - $33.42 - $48.46 

Candidates for this position must reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties) or be willing to relocate to the area upon hire. As a community-facing role, a local presence is essential to effectively engage with and serve our community. Please note that relocation assistance may be available.

Job Summary

The D-SNP Community Health Worker (CHW) is a non-licensed, non-clinical member of the Care Management team who engages dual-eligible members and caregivers by phone, in the community, and in the home where applicable to build trust and remove practical barriers to care.

Duties and Responsibilities

• Member and Caregiver Engagement & Support:
   

  • Outreach to introduce the program, confirm consent, and explain CHW support and next steps.
     

  • Conduct home or community visits as applicable following safety procedures; observe environmental needs and report findings.
     

  • Manage an outreach/case list, prioritize by need, and meet required turnaround times and productivity standards.
     

  • Answer inbound calls and return messages; route issues to appropriate team members when outside CHW scope.
     

  • Coordinate interpreter/language services and ensure materials match member language preferences.
     

  • Participate in team huddles/ICT updates by sharing brief status and linkage progress (does not lead care planning).
     

  • Maintain HIPAA/confidentiality and professional boundaries; obtain/track consents or releases as required.
     

  • Other duties as assigned.
     

• Coordination of Services and Community Resource Navigation:
   

  • Schedule/reschedule medical, behavioral health, and LTSS appointments; place reminder calls/texts.
     

  • Coordinate transportation (non-emergent) and troubleshoot logistics barriers (e.g., directions, access).
     

  • Connect members to community resources/benefits (e.g., IHSS, HCBS/CBAS, FQHCs, food and housing programs, utilities assistance); assist with referrals and applications.
     

  • Facilitate warm handoffs to providers, community agencies, and internal CM team members.
     

  • Support transitions of care (e.g., post-discharge check-ins, follow-up appointment reminders, pharmacy pick-ups).
     

  • Keep resource directories current and share tailored resource lists (mail/email/text) with members and caregivers.
     

  • Other duties as assigned.
     

• Social Needs Screening and Health Education:
   

  • Conduct brief social needs (SDOH) screenings with members/caregivers (not formal psychosocial assessments).
     

  • Support HRA outreach (reminders, scheduling, and assistance as allowed by protocol).
     

  • Provide basic health education and teach-back to reinforce care-plan tasks and self-management (no counseling/clinical instruction).
     

  • Other duties as assigned.
     

• Documentation, Communication, and Escalation:
   

  • Document all contacts, referrals, and outcomes accurately and on time