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

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.

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.

• 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…