Home Medi-Cal Community Health Worker Minimum Qualification Checklist

Medi-Cal Community Health Worker Minimum Qualification Checklist

Supervising providers, as defined in Medi-Cal policy, may use this checklist as a tool to track and document that a Medi-Cal Community Health Worker (CHW) under their supervision and for whom they intend to bill for services provided to Medi-Cal members meets all of the qualifications outlined in the Community Health Worker (CHW) Preventive Services section of the Medi-Cal Provider Manual, which is produced by the Department of Health Care Services (DHCS). When using this tool, please consider the following: 

  • CHW Certificates of Completion are not reviewed, issued, or approved by any California State agency, including DHCS. 
  • CHW Certificates of Completion may be issued by any organization, whether it be in California, in another state, or internationally so long as it meets all Medi-Cal policy requirements. 
  • The supervising provider is ultimately responsible for determining if the organization that issues the CHW Certificate meets all Medi-Cal policy and related requirements and the CHW is therefore qualified to provide services to Medi-Cal members. 

Note:  This page is intended to be an optional tool for supervising providers and may be used to supplement documentation that a CHW satisfies Medi-Cal policy requirements but does not replace the separate requirement to maintain a copy of the CHW’s Certificate of Completion. This page does not need to be submitted to DHCS, but must be made available to DHCS upon request or in the event of a state or federal audit.  

Section A – CHW and Supervising Provider Information   

This section may be used to identify both CHW and supervising provider information.  

  • CHW Name/Title: 
  • Supervising Provider Name/Title:  
  • Supervising Provider Organization:  
  • Employment Start Date:  
  • Employment Type (e.g., employee, contractor, volunteer)  

Section B – Qualification Verification   

This section may be used to document the pathway (Certificate or Work Experience) being used to demonstrate CHW Minimum Qualifications.  

  • CHW Certificate Pathway: The CHW possess a CHW Certificate of Completion that meets all Medi-Cal policy and related requirements as outlined in the Community Health Worker (CHW) Preventive Services section of the Medi-Cal Provider Manual, which includes demonstrated skills and/or practical training, which are outlined in Section C below.  
  • Violence Prevention Professional (VPP) Certificate: The CHW possess a VPP Certification issued by Health Alliance for Violence Intervention or a certificate of completion in gang intervention training from the Urban Peace Institute. 

Note: This pathway only allows CHWs to provide violence prevention services. For broader services, CHWs would need to meet the CHW Minimum Qualifications through either the Work Experience Pathway or CHW Certificate Pathway. 

  • Work Experience Pathway: The CHW has completed 2,000 hours working as a CHW in a paid or volunteer position within the previous three (3) years, and the CHW has demonstrated skills and practical training in the areas outlined in Section C below.  

Note:  CHWs who initially use the Experience Pathway to begin providing Medi-Cal services must earn a CHW certificate (following the Certificate Pathway above) within 18 months of rendering CHW services to a Medi-Cal member.  

Section C – Core Competency and Experience Tracker  

This section may be used to track CHW Minimum Qualifications (demonstrated skills and/or practical training) in core competency areas, as required in Medi-Cal policy. CHWs demonstrating qualifications under the Certificate Pathway must provide proof of a Certificate of Completion with a curricula that clearly includes skills and/or practical training in the following areas: 

  • Competency
    • 커뮤니케이션
    • Interpersonal Skills and Relationship Building
    • Service Coordination and Navigation
    • Capacity BuildingAdvocacy
    • Education and Facilitation
    • Individual and Community Assessment
    • Professional Skills and Conduct
    • OutreachEvaluation and Research
    • Basic Knowledge in Public Health Principles and Social Determinants of Health
  • Experience and/or Training Description
  • Date Completed
  • Supervising Provider Initials

Add additional pages as needed.

Section D – Certification 

This section may be used to certify that the information contained within in the checklist is accurate. 

Something such as “Check this box: I possess the requisite legal authority to submit this attestation on behalf of my organization. Further, I certify, under penalty of perjury, pursuant to applicable federal and state laws and as Medi-Cal policies, that all information provided in this attestation form is true, correct, and complete to the best of my knowledge and belief” may be included.

A list of the following may also be included:  

  • Name: 
  • Title:  
  • 이메일: 
  • 전화:  
  • Signature:
  • 날짜.