Community Health Worker - Care Transitions & Navigation

Description

FLSA Status: Full-time, Non-Exempt

Compensation: $25.00-$31.00 per hour

Post Date: November 06, 2026

Close Date: November 20, 2026

Reports to: Project Manager

To apply for this position: Please submit a resume and cover letter. Your resume will not be considered if a cover letter is not included.

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 (CHW) – Care Transitions & Navigation helps individuals with complex health and social needs stay connected to care as they move between hospitals, clinics, and community services. You will respond to referrals, understand each client’s immediate priorities, help arrange appointments, and follow up on connections to care and resources.

The role includes helping clients understand Medi-Cal eligibility and health plan options, connecting them with enrollment and renewal assistance, and coordinating handoffs to appropriate programs, including CalAIM Enhanced Care Management (ECM) and Community Supports. This is a non-clinical, non-supervisory role within Integrated Care Navigation.

What This Work Looks Like

This is primarily field-based work, with office-based administrative time and telephone outreach throughout the week. You will balance new referrals with scheduled appointments, client and partner messages, outstanding follow-up, and documentation. A hospital referral or a client’s changing needs may require you to adjust your priorities and seek guidance from your supervisor.

Making a referral is often only one step. You may need to contact a client more than once, clarify information with a provider or health plan, help gather documents, and confirm whether the client connected with the service. Clear communication and organized follow-through are central to this work.

A Day in the Life

You may begin your day reviewing new referrals, scheduled appointments, follow-up tasks, and messages from clients or partners. You might contact someone referred during a hospital visit, complete an intake and needs assessment with clients in real time at the hospital or other community locations, confirm information, and identify their most immediate priorities.

Later, you may help complete CalAIM referrals, schedule follow-up visits with the client, coordinate primary care, behavioral health and/or specialty appointments, connect clients to shelter or recuperative car, explain Medi-Cal options, help a client gather documents for an application or renewal, and connect them with CoHeWo’s Health & Benefits Access team, CoHeWo’s Street Outreach team, or their CalAIM CHW. You may also follow up with a health plan, provider, partner, or another CoHeWo team about a referral or service connection.

Throughout the day, you will document services in Salesforce Nonprofit Cloud (NPC), track next steps, and respond to incoming needs. Team meetings and case conferences provide opportunities to discuss barriers and coordinate support.

What You’ll Do

Care transitions and client navigation

• Respond to referrals from hospitals, clinics, shelters, outreach teams, healthcare providers, managed care plans, and community partners.
• Conduct in-person and telephone outreach to clients with approved service authorizations and engage them in the navigation process.
• Complete intake and needs assessments, confirm eligibility, and obtain required consents.
• Identify clients’ immediate priorities and barriers to care and help connect them with appropriate resources.
• Help clients schedule and prepare for medical, behavioral health, and social service appointments. Help clients connect to shelter and recuperative care placements in partnership with hospital staff and CoHeWo patient navigation CHWs.
• Support timely connections during care transitions and coordinate handoffs to care management and community support programs, including CalAIM ECM and Community Supports.
• Follow up on referrals, appointments, and outstanding needs, and communicate next steps to clients and partners.

Medi Cal and coverage navigation

• Help clients understand Medi-Cal eligibility, navigate health plan options, and connect with appropriate resources for enrollment and renewal.
• Help clients gather required documents and prepare for enrollment or renewal appointments.
• Coordinate with CoHeWo’s Health & Benefits Access team and other enrollment resources and follow up to support continuity of coverage.
• Provide understandable information within the scope of the role and seek guidance when eligibility rules or client circumstances are unclear.

Documentation communication and teamwork

• Build respectful relationships and provide culturally responsive, person-centered support.
• Maintain accurate and timely client records, service notes, referrals, follow-up tasks, and outcomes in Salesforce NPC and other approved systems.
• Participate in team meetings and case conferences and coordinate with other CoHeWo teams and external partners.
• Communicate workflow challenges, service barriers, and situations requiring guidance to your supervisor.
• Protect client confidentiality and follow HIPAA requirements and organizational policies.
• Responsibilities may change based on organizational or program needs. Other related duties may be assigned.

What Success Looks Like

• Clients feel heard, respected, and supported, and understand the next steps available to them.
• Referrals, appointments, and outstanding needs receive consistent follow-up, helping reduce avoidable gaps in access to care and services.
• Client records are accurate, complete, and documented within established timelines.
• Handoffs include the information needed for the receiving team or partner to continue support.
• You remain compassionate and responsive while respecting client choices and maintaining professional boundaries.
• You recognize when a situation requires consultation and involve your supervisor or the appropriate team.

What Can Be Challenging About This Work

No two days will look exactly the same. New referrals and time-sensitive needs may arise while you are following up with other clients. You will need to organize competing tasks, communicate clearly, and complete timely documentation alongside client support.

Clients may be experiencing significant health and social challenges and may feel frustrated, worried, or overwhelmed. The work requires patience and respectful communication while following established processes, maintaining boundaries, and seeking support when needed.

A referral or appointment may require several follow-up attempts. Delays, missing documents, difficulty reaching a client, or limited service availability can affect progress. You are expected to follow through on the steps within your role and communicate barriers, even when the final outcome depends on a client, provider, health plan, or another agency.

How CoHeWo Supports You

• Onboarding and guidance on care navigation workflows, Medi-Cal resource connections, and assigned documentation systems.
• Supervisor guidance on priorities, professional boundaries, and situations requiring escalation.
• Team meetings and case consultation to discuss client needs, barriers, and next steps.
• Coordination with Health & Benefits Access and other CoHeWo teams for services outside this role’s scope.

Requirements

What We’re Looking For

Required education and experience

• High school diploma or GED.
• One to two years of experience in community health, navigation, outreach, or a related role.

Knowledge and skills

• Working knowledge of Medi-Cal and CalAIM programs.
• Clear, respectful communication and the ability to explain information in an understandable way.
• Strong organization, consistent follow-through, and attention to accurate documentation.
• Cultural humility and experience working with diverse communities.
• Ability to maintain confidentiality and professional boundaries, and seek guidance when needed.

Helpful experience

• Experience supporting Medi-Cal or public benefits navigation.
• Lived experience navigating healthcare or social service systems that you choose to share.

Applicants do not need to meet every preferred qualification to be considered.

Requirements and Conditions of Employment

• Valid California driver’s license, current automobile insurance, and reliable transportation for travel within Sacramento County and surrounding areas.
• Completion of required criminal background screening and applicable partner-site requirements.
• Ongoing compliance with organizational policies and maintenance of any licenses or certifications required for the assignment.

Work Environment and Schedule

This is a full-time, non-exempt position, scheduled Monday through Friday. Hours may vary based on program needs. Work occurs primarily in an office setting at 819 19th Street in Sacramento, with coordination across healthcare and community systems. Field coordination and occasional local travel may be required.

Physical and Emotional Demands

The role requires frequent sitting, standing, walking, and computer use. The employee may occasionally lift or move items weighing up to approximately 15 pounds.

The position involves interaction with people experiencing complex health and social challenges.

Employees must communicate clearly, maintain professional boundaries, and respond appropriately in emotionally sensitive or time-sensitive situations. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position.

How to Apply

To apply, please submit:

1. Completed application.

2. A resume describing your relevant experience and skills.

3. A brief cover letter explaining your interest in Community HealthWorks, what draws you to this position, and how your experience, skills, or perspective would help you contribute in the role.

We appreciate your interest in joining Community HealthWorks.