Housing Community Supports Navigator

Description:

Wellness Equity Alliance (WEA) is a novel national public health organization comprised of a multidisciplinary team of population and public health experts with backgrounds in infectious disease, public health, emergency medicine, primary care, cardiology, pediatrics, psychiatry, community health work (CHW), nursing and advanced practice pharmacy. We work nearly exclusively with underrepresented communities, fundamentally addressing health-care disparities and the social determinants of health (SDoH) that have been amplified during the COVID-19 pandemic, prioritizing the following:

• People experiencing homelessness
• Indigenous communities
• Immigrant communities
• Rural communities
• BIPoC communities
• LGBTQIA+ communities
• Justice-impacted communities

Overview

Street Medicine provides direct healthcare to unhoused individuals, wherever they are, with a strong focus on assessing and responding to their physical, social, and psychological needs. Staff selected for this role will contribute to a vital and sustainable street medicine program designed to serve unhoused communities in the Coachella Valley area. Often, the most vulnerable individuals experiencing homelessness have encountered repeated failures from institutions throughout their lives, leading to a deep mistrust of authorities, institutions, and healthcare providers. This mistrust, while initially a form of self-protection, can become a significant barrier to accessing care and resources that could significantly improve their quality of life.

Enhanced Care Management (ECM) is a statewide Medi-Cal benefit available to select members with complex needs. Enrolled members receive comprehensive care management from a lead care manager who coordinates all health and health-related care, including physical, mental, and dental care, as well as social services. ECM facilitates access to the right care at the right time, in the right setting, beyond traditional healthcare environments.

Community Supports (CS) are services provided by Medi-Cal managed care plans (MCPs) that address health-related social needs, promoting healthier lives and reducing the need for higher, costlier levels of care.

Purpose of the position

The Housing Community Supports Navigator plays a key role within WEA’s CalAIM Community Supports program. This is a non-clinical position responsible for helping Medi-Cal members—particularly people experiencing homelessness or housing instability—navigate the housing system, secure appropriate resources, and connect with services that support long-term stability.

The Navigator builds relationships with members, providers, housing partners, and community organizations to ensure individuals receive timely, person-centered, and effective support across both health and housing domains.

Key Responsibilities

• Conducts proactive outreach and engagement with patients through various methods, including in-person field visits, phone calls, and text messaging to encourage enrollment in WEA services and programs.
• Serves as an advocate to patients, helping them navigate health care and social service systems to access necessary resources.
• Conducts comprehensive assessments of patients’ health, behavioral/mental health, and social needs using WEA prescribed forms or any other standardized tools to
• Develops, implements, and monitors individualized care plans that address identified medical, behavioral, and social determinants of health needs, utilizing coaching, motivational interviewing, and other evidence-based techniques to support patients in achieving their goals.
• Promotes patient’s self-management and empowerment by connecting them to community resources, housing, transportation, and other social supports, including accompanying patients to office visits or community services as deemed necessary.
• Identify barriers to achieving targeted clinical or social outcomes, and engage the care team to revise the care plan when necessary (case conferences).
• Promotes and monitors treatment adherence.
• Closely follows up with unhoused patients who are at greater risk for avoidable ER utilization and hospital readmissions.
• Ensures all care management activities, patient interactions, and care plans are documented in accordance with organizational and regulatory standards.
• Participates in program/service audits and quality improvement initiatives to enhance the effectiveness of the WEA service model.
• - Serve as a certified Presumptive Eligibility (PE) Determiner for Medicaid, conducting eligibility screenings and completing enrollment forms in compliance with New Mexico Human Services Department (HSD) guidelines.
• - Assist individuals with completing and submitting Medicaid and other health coverage applications, renewals, and verifications.
• - Educate community members on public health coverage options, including Medicaid and local health programs.
• - Track and follow up with applicants to ensure timely submission and transition to ongoing coverage.
• - Maintain accurate and confidential documentation of all eligibility and enrollment activities in accordance with HIPAA and organizational policies.
• - Participate in Medicaid PE training and stay current with eligibility policy updates and procedural requirements.

Housing Navigation-Specific Responsibilities

• Provides advocacy for unhoused patients to secure shelter or permanent housing.
• Collaborates and develops working relationships with local housing/shelter providers and other related social agencies.
• Is a point of contact for the Street Medicine team for homeless services/programs, including shelters, recuperative care, recovery and other related services.
• Assists members in completing Coordinated Entry System (CES) assessments through the Homeless Management Information System (HMIS)
• Assists in obtaining housing readiness documentation.
• Assists patients in identifying appropriate housing and completing housing applications.
• For patients who secure housing, assists with housing deposits and supports with housing tenancy education/resources.
• Keeps the Street Medicine Team abreast of programs serving the unhoused community.

Requirements:

Minimum Qualifications One of the Following

• Demonstrated knowledge of and experience with local/regional community resources
• Demonstrated ability to provide appropriate guidance and positive customer service utilizing a patient-centered approach.
• Ability to work both independently and to collaborate with teams of individuals in diverse settings, using a solution-oriented approach.
• Demonstrated knowledge of public health/social program services the unhoused.
• Ability to maintain confidentiality and privacy of persons, documents and information.
• Skilled in computer applications and EMR
• Must possess a valid driver’s license.

Education Experience

• High School diploma or general equivalency diploma (GED) Associate's degree in a healthcare, social work, or related field (Preferred)

Preferred Skills

• 2–3 years of experience in housing navigation, case management, or homeless services.
• Training or experience in Motivational Interviewing, Trauma-Informed Care, Harm Reduction, Crisis Intervention, or De-escalation.
• Familiarity with data systems and strong proficiency in Google suite programs.
• Experience with community outreach or engagement activities.
• Bilingual English/Spanish is highly desirable.