Enhanced Care Management & Community Supports Peer Navigator (San Fernando Valley, CA)

At Healthcare in Action, we serve patients experiencing homelessness through an innovative "street medicine" approach by contracting with Medicare and Medicaid health plans as well as hospitals and health systems.

Street medicine entails using a medically equipped van to deliver medical care directly to people experiencing homelessness in locations such as parking lots, encampments, and parks.

The Enhanced Care Management & Community Supports Peer Navigator supports members throughout the San Fernando Valley, Duarte, and surrounding areas who are experiencing homelessness, housing instability, or residing in temporary and interim housing settings.

This position works closely with hospital social workers, case managers, discharge planners, interdisciplinary care teams, housing providers, and community-based organizations to support safe transitions from inpatient and outpatient settings into the community through person-centered care coordination, housing navigation, and continuity of care support.

Many members supported through this role have complex medical and social needs and may be actively undergoing cancer treatment or other ongoing medical treatment requiring medically appropriate discharge planning, recuperative care, interim housing, or alternative placement options that support ongoing treatment and medical stability.

In addition to supporting hospital-based referrals, this position will maintain a dually enrolled Enhanced Care Management (ECM) and Community Supports panel supporting members experiencing homelessness, housing instability, or residing in temporary and interim housing programs.

Responsibilities include:

• Collaborate closely with hospital social workers, case managers, discharge planners, and interdisciplinary care teams to support discharge planning, continuity of care, and transitions into the community.
• Experience supporting individuals with complex medical and social needs, including post-hospitalization discharge coordination, care transitions, hospital-based care coordination, recuperative care placement, or medically vulnerable populations preferred.
• Experience working with individuals experiencing acute or ongoing medical conditions requiring continuity of care, treatment adherence, or medically appropriate placement support strongly preferred.
• Conduct person-centered and trauma-informed care coordination and housing navigation activities consistent with CalAIM Enhanced Care Management (ECM) and Community Supports (CS) service expectations.
• Assist members in identifying and accessing interim housing, recuperative care, shelter placements, permanent supportive housing, and other medically appropriate placement options.
• Coach members to create and implement strategies that minimize risks associated with identified health conditions and barriers to care.
• Support members in obtaining identification documents, benefits enrollment, transportation resources, and linkage to medical, behavioral health, and community-based services.
• Coordinate and/or accompany members to medical and social services appointments as appropriate.
• Collaborate with housing providers, shelters, recuperative care programs, interim housing programs, and community organizations to facilitate placement opportunities and stabilization support.
• Support members who may not be appropriate for traditional shelter or housing environments due to ongoing medical treatment or clinical complexity.
• Conduct field-based outreach and community visits as needed to support ongoing engagement and continuity of care.
• Complete all required organizational, contractual, and CalAIM-specific documentation in a timely fashion, including documentation in EPIC and other required systems.
• Maintain accurate records of member engagement, care coordination activities, housing navigation efforts, and Plan of Care updates.
• Actively support the achievement of HIA's Vision and Goals, particularly housing stability and improved health outcomes for members experiencing homelessness.
• This position is a patient-facing role.
• We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.
• Other duties as assigned.

Qualifications and experience:

• G.E.D./High School, required plus 3+ years of work experience as defined below.
• Associate's Degree plus 2+ years of work experience as defined below.
• Bachelor's degree preferred plus 1+ years of work experience as defined below.
• Work Experience to include direct work experience, lived experience, training or volunteer work with patients experiencing homelessness, as well as those with active mental health and substance use conditions.
• Other demonstrated relevant experience in similar community settings, for example, working with other disadvantaged groups, and/or outreach will be considered.
• A comparable combination of education/experience and/or training will be considered equivalent to the education listed above.]
• Demonstrated experience with ECM and CSS strongly preferred.
• Ability to work in a dynamic, outdoors environment.
• Ability to work independently as well as part of a team.
• Ability to organize effectively.
• Ability to prioritize multiple and competing tasks.
• Ability to communicate effectively, including articulating one's own relevant personal experiences.
• Excellent oral communication skills, as well as strong interpersonal skills.
• Maintenance of reliable transportation.
• Proficiency in operating a computer, including logging into and maneuvering around multiple systems such as online timesheets (time and attendance) and call center software.
• HMIS/ Coordinated Entry System, preferred.
• Travel 50% or more- Must have a valid driver's license, automobile insurance, reliable transportation, and clean driving record.

What's in it for you?

• Base salary range: $21.78 to $33.00 per hour
• Medical, Dental, Vision coverage
• An annual employee bonus program
• Robust Wellness Program
• Generous paid-time-off (PTO)
• 11 paid holidays per year, plus 1 additional floating holiday
• Excellent 401(k) Retirement Saving Plan with employer match.
• Robust employee recognition program
• Tuition reimbursement
• An opportunity to become part of a team that makes a difference to our members and our community every day!

At Healthcare in Action, we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.

Healthcare in Action is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employee will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

Healthcare in Action was established in 2021 as a 501 (c)3 organization and associated medical group. Utilizing mobile clinics staffed by healthcare professionals, community health workers, and social workers, our teams travel directly to unhoused individuals living in communities across the geographies we serve, providing services where they reside - including tents, cars, shelters, and temporary housing. In meeting patients where they are and supporting their goals, HIA team members build trust - a critical component that can lead to meaningful and positive changes in health and housing. Our mission is to improve the lives of people experiencing homelessness through quality holistic care. It is our vision that all people experiencing homelessness have access to quality healthcare that addresses their mental, social and physical health needs.