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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 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.
  • Strong understanding of healthcare systems, managed care, and community resources.
  • Strong organizational and time management skills.
  • 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.
  • Comfort navigating multiple systems and communication platforms.
  • Ability to travel locally within Monterey County.
  • Valid California driver's license and reliable transportation.
  • Ability to work in a hybrid, field-based environment.
  • Ability to work independently in field and remote environments, manage complex caseloads and competing priorities, and provide high-volume documentation and complete records of member interactions.
  • Comfort and compassion working with individuals experiencing severe mental health challenges, with emotional intelligence and de-escalation techniques for crisis situations.

Responsibilities

  • Support members participating in CalAIM Community Supports housing programs, including Housing Transition Navigation Services, Housing Tenancy and Sustaining Services, and Housing Deposit assistance.
  • Conduct outreach and intake assessments for members in need of housing.
  • 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.
  • Spend approximately 65% of work time in the field, including home inspections, shelters, and community settings; conduct in-person visits, assessments, and follow-ups; and travel locally within the county and surrounding counties.
  • Manage and coordinate the application pipeline for housing resources, including processing Housing Deposit Services packages 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 according to state guidelines.
  • Provide Housing Transition Navigation Services to help members experiencing or at risk of homelessness transition to stable housing while coordinating healthcare and community-based services.
  • Coordinate Housing Tenancy and 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 documentation and facilitating access to deposit assistance.
  • Collaborate with housing authorities, landlords, shelters, property managers, healthcare providers, and community organizations to support housing placement and long-term tenancy.
  • Monitor housing stability and proactively address barriers that could put housing or health outcomes at risk.
  • 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; and ensure continuity of care and follow-through.
  • Build trusting relationships with members and families, provide support through phone, video, and in-person visits, and advocate for timely care, services, and equitable access to resources.
  • Represent the organization through community outreach, partnerships, and local initiatives; maintain relationships with community organizations, shelters, and service providers; identify opportunities to improve access; and support outreach that increases member engagement and program awareness.
  • Connect members to housing resources and assist with long-term housing; strengthen community partnerships; identify resource gaps and escalate needs for program improvement.
  • Participate in departmental huddles, share housing resources in team channels, provide cross-coverage to peers, assist with new Lead Care Managers' shadowing sessions, and promote consistency and best practices across the team.
  • Maintain accurate and timely documentation of member interactions; comply with Medi-Cal, CalAIM, and Community Supports program requirements; and track progress, outcomes, and service delivery.
  • Partner with behavioral health, outreach, and social services teams, and coordinate with healthcare providers and payers for seamless care delivery.
  • Identify service trends and gaps and collaborate with leadership during coaching syncs to incorporate feedback and refine daily workflows.
  • Manage the caseload independently, maintain member engagement and continuity of care, support housing stabilization milestones and placements, coordinate services timely, and maintain accurate documentation and program compliance.

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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