Community Health Worker, CalAIM – ECM (Justice-Involved Population)

Community HealthWorks; Sacramento (CA); On-site; USD 52,000 - 64,000; Full time

Job summary

Community HealthWorks is hiring a Community Health Worker to support Medi-Cal members transitioning from incarceration, delivering Enhanced Care Management in the community. You will engage members, coordinate care, and help connect them with housing, benefits, and services.

The role emphasizes fieldwork in community settings, documentation, and collaboration with clinical teams to maintain continuity of care after release.

Qualifications

• High school diploma or GED required.
• Ability to build respectful relationships with diverse populations.
• Strong communication and organizational skills.
• Experience coordinating care across healthcare and community partners.

Responsibilities

• Conduct in-person and telephone outreach to Medi-Cal members receiving ECM.
• Build trusting relationships and help members identify goals and next steps.
• Provide post-release engagement and reentry support.
• Complete warm handoffs for members transitioning to ECM services.
• Document care plans and update follow-up tasks.

Skills

Relationship-building

Communication

Care coordination

Case management

Fieldwork

Education

High school diploma or GED

Tools

Microsoft Office

Job description

FLSA Status: Full-time, Non-Exempt

Compensation: $25.00-$31.00 per hour

Post Date: October 07, 2026

Close Date: October 23, 2026

Report to: Project Manager

About Community HealthWorks

Community HealthWorks (CoHeWo) advances health equity by helping individuals and families access the health coverage, care, housing support, and community services they need to thrive. We work at the intersection of healthcare and community support, partnering with managed care plans, health systems, community-based organizations, and government agencies to remove barriers to care.

Community Health Workers are central to this work. They serve as trusted connectors who help people understand complex systems, identify their own goals, and take practical next steps toward greater health and stability.

Position Summary

The Community Health Worker, CalAIM works primarily in the community with Medi-Cal members receiving Enhanced Care Management (ECM). This assignment focuses on members transitioning from incarceration into the community who may also be experiencing multiple chronic health conditions, behavioral health needs, substance use, housing instability, disrupted access to healthcare or medications, or other barriers to care.

Through Enhanced Care Management, the CHW provides post-release engagement, care coordination, and reentry support to help members address complex health and social needs and maintain connections to care and services following release. The CHW works closely with the Pre-Release Care Coordinator, clinical team, health plans, healthcare providers, community partners, and other CoHeWo teams to support continuity of care and address barriers to successful community reintegration.

The CHW carries an active caseload and works with members to identify their goals, understand available options, and take practical next steps toward greater health and stability. This is a non-clinical, non-supervisory role.

What This Work Looks Like

This is a relationship-based, field-focused position. Approximately 60% of the work takes place in the community and 40% involves documentation, phone outreach, service coordination, team meetings, and follow-up. Work may occur in shelters, homes, clinics, hospitals, government offices, housing locations, community-based organizations, and other partner sites.

For this assignment, care coordination is focused on supporting members as they transition from incarceration back into the community. For this assignment, the CHW provides ongoing ECM services to members transitioning from incarceration back into the community. When CoHeWo is the member’s selected ECM provider, the CHW participates in the warm handoff from pre-release services, takes the member onto their ECM panel, and provides ongoing community-based care coordination following release.

Needs and circumstances can change quickly during reentry. A healthcare appointment may need to be scheduled or rescheduled, medications may need follow-up, housing or transportation plans may change, or new needs may emerge after release. The CHW helps the member navigate these changes while coordinating with appropriate healthcare, community, and justice-system partners.

The work requires flexibility, clear communication, sound judgment, professional boundaries, and the ability to work independently while remaining connected and accountable to the team.

A Day in the Life

You may begin your day by reviewing your caseload, responding to messages, and coordinating with teammates, health plans, healthcare providers, or community partners.

You might connect with a member who recently returned to the community to review their care plan and priorities, confirm an upcoming healthcare appointment, help address a medication or transportation need, or identify a new barrier that has emerged since release.

Later, you may accompany a member to an important appointment, coordinate with a healthcare or behavioral-health provider, help connect the member with housing or benefits resources, or work with the Pre-Release Care Coordinator to follow through on services or referrals initiated before release.

You will also document services provided, update care plans and follow-up tasks, communicate with partners, and continue outreach when circumstances change or a member is difficult to reach.

No two days will look exactly the same, but timely follow-through, accurate documentation, continuity of care, and respect for member autonomy are always part of the work.

What You’ll Do

Member engagement and direct support

• Conduct in-person and telephone outreach to Medi-Cal members receiving Enhanced Care Management.
• Build respectful, trusting relationships and help members identify their goals, understand their options, and take practical next steps.
• Provide post-release engagement and reentry support to members transitioning from incarceration into the community.
• Participate in and complete warm handoffs for members transitioning from pre-release services to CoHeWo for ongoing ECM services.
• Review the member’s existing care plan, identified needs, referrals, and community connections and continue care coordination following release.
• Meet members in community settings and accompany them to medical, housing, benefits, and other important appointments when appropriate.
• Connect members with essential resources such as food, clothing, water, shelter, transportation, and community-based services.
• Provide support during urgent or emotionally difficult situations, follow organizational safety and escalation practices, and recognize the limits of CoHeWo’s non-emergency role.

Healthcare and care coordination

• Complete required health and social-needs assessments and develop or update care plans with members.
• Help members establish or reconnect with primary care and other healthcare providers following release.
• Support scheduling and follow-through for medical, behavioral-health, or other healthcare appointments.
• Help address medication-related needs following release by coordinating with appropriate healthcare, pharmacy, or clinical partners.
• Help members maintain health coverage, follow up on healthcare needs, and communicate with health plans and providers.
• Connect eligible members with behavioral health, substance-use, County Mental Health, System of Care, and other appropriate services.
• Recognize when a healthcare or medication-related need is outside the CHW’s role and involve the appropriate clinical provider or team member.

Reentry and community coordination

• Coordinate with the Pre-Release Care Coordinator to support continuity of care and services as members transition into the community.
• Follow up on referrals, appointments, services, and other needs identified before release.
• Help members address housing, transportation, identification, benefits, employment, and other social needs that may affect health and stability following release.
• Support housing navigation, including housing-readiness documents, referrals, applications, prospective housing opportunities, and move-in coordination.
• Help members obtain identification, Social Security cards, income verification, and other documents needed to access services, benefits, or housing.
• Coordinate with healthcare providers, health plans, community-based organizations, other CoHeWo teams, and justice-system partners as appropriate to the member’s care and reentry needs.
• Coordinate with probation or parole when appropriate and relevant to the member’s care coordination needs.
• Help reduce gaps and duplication as members move between healthcare, community, and other service systems.

Documentation, communication, and teamwork

• Maintain timely, complete, and accurate member records, service notes, assessments, activity logs, mileage logs, referrals, and required reports.
• Document coordination, referrals, follow-up needs, and outstanding next steps so members can receive informed and continuous support.
• Use assigned electronic systems and standard office technology to track services, follow-up needs, and outcomes.
• Protect member privacy and comply with HIPAA, confidentiality requirements, and organizational policies.
• Participate in supervision, team meetings, case conferences, training, and community meetings.
• Communicate changes, safety concerns, barriers, and situations requiring guidance to the appropriate supervisor or team member.

What Success Looks Like

Successful CHWs do not solve every problem for a member. They consistently help people understand their options, move toward self-identified goals, and remain connected to available support.

Success in this role includes:

• Building trust while respecting each member’s autonomy, privacy, choices, and individual circumstances.
• Helping members remain connected to healthcare and community services during the transition back into the community.
• Support effective handoffs and follow-through so that care and service planning can continue after release.
• Following through on commitments and communicating when circumstances, appointments, services, or plans change.
• Completing accurate documentation and required follow-up within established timelines.
• Using sound judgment, professional boundaries, and organizational safety practices.
• Working collaboratively across healthcare, community, and justice systems while understanding the limits of the CHW role.
• Knowing when to ask for consultation or support.
• Responding to setbacks with patience, curiosity, and a focus on practical next steps.

What Can Be Challenging About This Work

Members transitioning back into the community after incarceration may be navigating multiple needs at once, including serious health conditions, behavioral-health needs, substance use, housing instability, disrupted family relationships, employment barriers, benefits or identification needs, or other challenges affecting health and stability.

The period following release can also be unpredictable. Plans made before release may change, healthcare or medication needs may require timely follow-up, a member may be difficult to reach, or community resources may have waitlists or eligibility requirements. Some needs cannot be resolved immediately.

You may support someone through an urgent situation, witness difficult living conditions, experience setbacks after significant effort, or encounter circumstances outside CoHeWo’s control. Progress is rarely linear, and members may make choices that differ from what you or others would choose for them.

This work requires patience, emotional presence, adaptability, sound judgment, and professional boundaries. It also requires recognizing your own response to difficult circumstances, using supervision appropriately, and remaining effective without taking sole responsibility for another person’s choices, another system’s decisions, or a member’s outcome.

How CoHeWo Supports You

Employees are expected to ask for support and are not expected to navigate complex situations alone. Support for this role includes:

• Structured onboarding, field shadowing, and reverse shadowing before independent work.
• Training in Enhanced Care Management, reentry coordination, professional boundaries, field safety, confidentiality documentation, and required program systems.
• Guidance and established workflows for coordinating with Pre-Release Care Coordinator and supporting member transitions.
• Regular supervision, case consultation, and team-based problem solving.
• Access to colleagues with healthcare, behavioral-health, housing, benefits, reentry, and other subject-matter expertise.
• Clear escalation pathways and guidance about the limits of the role.
• Access to employee wellbeing and mental health resources available through CoHeWo’s benefits programs.

Requirements

What We’re Looking For

Required

• High school diploma or GED.
• Ability to build respectful relationships with people from varied backgrounds and life circumstances, including people transitioning back into the community after incarceration.
• Clear communication, organization, confidentiality, attention to detail, and consistent follow-through.
• Ability to listen, identify needs and goals, explain complex information clearly, and support practical next steps.
• Ability to coordinate respectfully with healthcare, community, government, and justice-system partners.
• Comfort learning and using electronic documentation systems, email, and Microsoft Office tools.
• Ability to work independently in community settings while remaining accountable and connected to a team.

Relevant experience that may help you succeed

Relevant experience may come from paid work, volunteering, education, caregiving, community involvement, or lived experience that you choose to share. Applicants do not need to meet every preferred qualification to be considered.

Helpful experience may include:

• Community health, outreach, peer support, case management, health navigation, housing services, behavioral health, substance-use services, or work alongside people experiencing homelessness.
• Experience working with people affected by incarceration and returning to the community.
• Experience coordinating across healthcare, social-service, government, or justice systems.
• Knowledge of Medi-Cal, CalAIM, Enhanced Care Management, Sacramento’s health care, housing and benefits systems, or local health and social-service resources.
• Community Health Worker, peer-support, substance-use, behavioral-health, or health-coverage enrollment training or certification.
• Postsecondary education in social work, behavioral health, public health, criminal justice, or a related field.

Requirements

• Valid California Class C driver’s license, current auto insurance, reliable transportation, and ability to travel throughout Sacramento County and surrounding areas.
• Completion of a criminal background check. Findings will be reviewed in relation to the position and in accordance with organizational policy and applicable law.
• Compliance with health-screening, certification, safety, and partner-site requirements applicable to the assignment.
• Maintenance of required training, certifications, and renewals associated with the role.

Work Environment & Schedule

This is a full-time, non-exempt position, typically Monday through Friday, 8:00 a.m. to 4:30 p.m. Occasional evening or weekend work may be required based on member or program needs. Work schedules are subject to change. Approved overtime will be compensated in accordance with applicable law and organizational policy.

Community-based work may take place in shelters, homes, clinics, hospitals, government offices, housing locations, community-based organizations, and other partner locations.

Fieldwork may involve variable weather, uneven terrain, noise, interruptions, animals, limited sanitation, or other environmental conditions. Employees are expected to assess conditions, follow field-safety practices, and consult a supervisor when circumstances exceed the role’s scope or can no longer be approached safely.

Physical & Emotional Demands

The employee must be able to frequently sit, stand, walk, speak, listen, use a computer, write, and operate standard office equipment. Fieldwork may include walking on uneven terrain. The employee may occasionally bend, stoop, kneel, reach, climb or balance, and lift or move approximately 10–15 pounds. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position.

The role includes regular interaction with people experiencing emotionally sensitive, urgent or unpredictable circumstances. The employee must be able to communicate effectively, use sound judgment, maintain appropriate professional boundaries, follow safety and escalation procedures, and seek supervision or support when needed.