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Pacific Health Group

Integrated Medi-Cal care coordination provider

Community Supports Lead Care Coordinator - Housing

Case Management & AdvocacyConfirmed live in the last 24 hours
Full-timeCalifornia, USA

About the Job

Requirements

  • Strong understanding of the housing system and demonstrated working knowledge of local housing resources, housing navigation, community-based support programs, or transitional housing support workflows such as Medi-Cal, CalAIM, Community Supports, or HUD programs.
  • Three to five years of experience in case management, social services, or healthcare.
  • Experience independently managing an active caseload in a care coordination, housing navigation, or case management environment.
  • Strong understanding of healthcare systems, managed care, and community resources.
  • Proficiency with technology, including case management systems, electronic health record platforms, and documentation tools.
  • Ability to document in real time and manage member data accurately.
  • Ability to navigate multiple systems and communication platforms.
  • Ability to travel within the hiring county and surrounding counties.
  • Valid California driver's license and active auto insurance meeting California requirements.
  • Reliable personal vehicle for daily work use.

Responsibilities

  • 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 comprehensive intakes to identify the housing needs of people who are unhoused or at risk of homelessness.
  • Build partnerships with housing providers, shelters, landlords, and community organizations to improve housing access and long-term stability.
  • Provide person-centered housing care management to a diverse panel of high-needs members, including individuals experiencing severe mental health conditions and substance dependencies.
  • Conduct face-to-face case management in shelters, community settings, and residences, including in-person housing assessments, unit habitability inspections, and active member outreach as needed.
  • Manage and coordinate the housing-resource application pipeline, including processing Housing Deposit Services packages by gathering required documentation and coordinating landlord allocations.
  • Participate in community outreach events, partnerships, and local engagement to build referral routes.
  • Navigate multiple primary platforms concurrently.
  • Complete high-fidelity chart notes and clinical documentation in real time in accordance with state guidelines.
  • Manage a caseload of 60–70 members experiencing chronic housing instability through end-to-end care coordination, housing barrier mitigation, and persistent outreach.
  • Provide Housing Transition Navigation Services to help members transition into stable long-term housing while coordinating healthcare and community-based services.
  • Coordinate Housing Tenancy & Sustaining Services through ongoing case management, advocacy, landlord engagement, and connections to healthcare, behavioral health, and community resources.
  • Assist members with housing deposits by coordinating required documentation and facilitating access to deposit assistance.
  • Collaborate with housing authorities, landlords, shelters, property managers, healthcare providers, and community-based organizations to support successful housing placement and long-term tenancy.
  • Monitor members' housing stability and proactively address barriers that could put housing or health outcomes at risk.
  • Perform member-management activities, including high-volume telephonic and field outreach, initial intake assessments, care-plan development, monthly touchpoints, and crisis escalation while maintaining compliance and documentation standards.
  • 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.
  • Build trusting relationships with members and their families.
  • Support members through phone, video, and in-person visits.
  • Advocate for timely care, services, and equitable access to resources.
  • Represent the organization at community 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 increase member engagement and program awareness.
  • Connect members to housing resources and assist them in obtaining long-term housing.
  • Strengthen partnerships with community-based organizations.
  • Identify resource gaps and escalate needs for program improvement.
  • Participate in departmental huddles, share housing resources in team channels, and provide cross-coverage support to peers.
  • Assist with shadowing sessions for new Lead Care Managers.
  • Promote consistency, collaboration, and best practices across the team.
  • Maintain accurate and timely documentation of member interactions.
  • Ensure compliance with Medi-Cal, CalAIM, and Community Supports program requirements.
  • Track progress, outcomes, and service delivery.
  • Partner with interdisciplinary teams, including behavioral health, outreach, and social services.
  • Coordinate with healthcare providers and payers to support seamless care delivery.
  • Identify trends and service gaps.
  • Collaborate with leadership during one-to-one coaching sessions to integrate feedback and refine daily workflows.

Desired Qualifications

  • Experience with Medi-Cal, CalAIM, and Community Supports programs.

About the Company

Pacific Health Group

Integrated Medi-Cal care coordination provider

Pacific Health Group provides integrated Medi-Cal care coordination in California, working with 39 health plans to serve more than 38,000 members across 44 counties. Its flagship Enhanced Care Management coordinates medical, behavioral, and social services for members with complex needs, complemented by Community Supports like housing navigation, rent assistance, medically tailored meals, and home modifications. Street Medicine reaches unsheltered individuals, while Community Health Workers provide culturally responsive care navigation and advocacy; additional services include behavioral health support, medical transportation, and a Clubhouse program for adults with mental illness. The approach follows CalAIM’s whole-person care, addressing social determinants of health to reduce fragmentation and improve stability for at-risk Medi-Cal beneficiaries.

Company size
51-200
Company stage
Not listed
Total funding
Not listed
Headquarters
Carlsbad, CA
Founded
2023

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