Community Supports Lead Care Coordinator (Housing)

Schedule : Monday – Friday | 8:30 AM – 5:00 PM Compensation : $30.00 – $35.00 per hour Location : Hybrid CA (Within hiring county) FLSA Status : Non-Exempt

About Pacific Health Group

At Pacific Health Group, we are at the forefront of revolutionizing health and wellness through innovation, compassion, and community-driven care. Our mission is to empower members, uplift families, and positively impact the communities we serve. Our Community Supports (CS) Program helps Medi-Cal members live more independently by addressing health-related social needs. In this role, you won’t just create care plans—you’ll guide members through every step of their journey, ensuring they receive the support and services needed to thrive.

What This Role Looks Like (Day-to-Day Reality)This is a highly field-based role supporting members directly in the community.

• Support members participating in CalAIM Community Supports Housing programs, including Housing Transition Navigation Services, Housing Tenancy & Sustaining Services, and Housing Deposit assistance.
• Conduct telephonic outreach and complete comprehensive intakes to identify housing needs of those who are unhoused or at risk of homelessness.
• Build strong partnerships with housing providers, shelters, landlords, and community organizations to improve housing access and long-term stability.
• Provide comprehensive, person-centered housing care management to a diverse panel of high-needs members (including individuals experiencing severe mental health conditions and substance dependencies).
• Spend 30–50% of your time in the field — delivering face-to-face case management across shelters, community settings, and residences. This includes conducting in-person housing assessments, unit habitability inspections, and active member outreach.
• Travel locally within the county and surrounding counties, including Marin, Napa, Solano, Sonoma, and Santa Cruz Counties
• Manage and coordinate the application pipeline for housing resources, including processing critical documents like Housing Deposit Services (HDS) packages by gathering required documentation to facilitate access to deposit assistance that removes financial barriers to securing permanent housing and coordinating landlord allocations.
• Participate in community outreach efforts including events, partnerships, and local engagement to build referral routes.
• Navigate seamlessly and concurrently across multiple primary platforms.
• Complete high-fidelity chart notes and clinical documentation in real-time following state guidelines.
• Manage a dynamic caseload of 60–70 members experiencing chronic housing instability, executing end-to-end care coordination, housing barrier mitigation, and persistent outreach.
• This role requires independence, strong time management, leadership capability, and comfort working in fast-paced, community-based environments.

What You’ll Do Housing Stability Services

• Support members experiencing homelessness or at risk of homelessness by providing Housing Transition Navigation Services, helping them successfully transition into long-term stable housing while coordinating healthcare and community-based services that address housing as a key social driver of health.
• Coordinate Housing Tenancy & Sustaining Services by helping members keep a stable housing through ongoing case management, advocacy, landlord engagement, and connections to healthcare, behavioral health, and community resources.
• Assist members with Housing Deposits, coordinating required documentation and facilitating access to deposit assistance that removes financial barriers to securing permanent housing.
• Collaborate with housing authorities, landlords, shelters, property managers, healthcare providers, and community-based organizations to ensure successful housing placement and long-term tenancy.
• Monitor members' housing stability and proactively address barriers that could place housing or health outcomes at risk.
• Possess the operational capacity and organizational skills to execute all aspects of member management—including high-volume telephonic/field outreach, initial intake assessments, care plan development, ongoing monthly touchpoints, and crisis escalation—while maintaining compliance and documentation standards.

Care Coordination & Case Management

• Conduct comprehensive member assessments to identify health and social needs.
• Develop and manage individualized housing care plans
• Coordinate appointments, services, and long-term housing support systems
• Ensure continuity of care and consistent follow-through

Member Engagement & Advocacy

• Build strong, trusting relationships with members and their families
• Provide ongoing support through phone, video, and in-person visits
• Advocate for timely care, services, and equitable access to resources

Community Outreach & Engagement

• Represent Pacific Health Group in the community through outreach events, partnerships, and local initiatives
• Build and maintain relationships with community-based organizations, shelters, and service providers
• Identify opportunities to expand community presence and improve access to services
• Support outreach efforts that drive member engagement and program awareness

Community Resource Navigation

• Connect members to housing resources and assist providing long term housing
• Strengthen partnerships with community-based organizations
• Identify gaps in resources and escalate needs for program improvement

Team Support

• Actively participate as a collaborative team player by maintaining an engaging, "camera-on" presence in all departmental huddles, sharing valuable housing resources in the team channels, and offering cross-coverage support to peers.
• Assist with new Lead Care Managers shadowing sessions
• Promote consistency, collaboration, and best practices across the team

Documentation & Compliance

• Maintain accurate and timely documentation of all member interactions
• Ensure compliance