Community Supports Lead Care Coordinator (Housing) - Sonoma/Napa County

Job Title

At Pacific Health Group, we are at the forefront of revolutionizing health and wellness through innovation, compassion, and community-driven care.

Job Description

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 outreach and complete intake assessments for members in need of housing
• 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 approximately 65% of your time in the field (home inspections, shelters, community settings)
• Conduct in-person visits, assessments, and follow-ups
• Travel locally within county and surrounding counties
• Manage and coordinate the application pipeline for housing resources, including processing critical documents like Housing Deposit Services (HDS) packages 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.
• This role requires independence, strong time management, leadership capability, and comfort working in fast-paced, community-based environments.

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.

Care Coordination & Case Management

• Conduct comprehensive member assessments to identify health and social needs.
• Develop and manage housing individualized 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 with Medi-Cal, CalAIM, and Community Supports program requirements
• Track progress, outcomes, and service delivery

Team Collaboration

• Partner with interdisciplinary teams including behavioral health, outreach, and social services
• Coordinate with healthcare providers and payers to ensure seamless care delivery

Continuous Improvement

• Identify trends and gaps in services
• Demonstrate a high level of professionalism by actively collaborating with leadership during 1:1 coaching syncs to integrate feedback and refine daily workflows.

How Success Is Measured

• Successful housing placements and housing retention for eligible members.
• Demonstrated continuous progression of member care through the care pipeline. This includes maintaining strong engagement with high-needs individuals, avoiding gaps in care, and successfully helping members meet their housing stabilization milestones.
• Timely coordination of Housing Transition Navigation Services, Housing Tenancy & Sustaining Services, and Housing Deposit assistance.
• Improved member health outcomes through housing stabilization and reduced barriers to care.
• Member engagement and successful care coordination outcomes
• Timely and accurate documentation
• Ability to manage caseload independently and effectively, and keeping your caseload active and continuously growing through effective outreach and timely enrollment strategies.
• Quality team support provided
• Strength of community partnerships and outreach engagement
• Compliance with program and regulatory requirements

Who Thrives in This Role

• Is comfortable working independently in the field and remote environments
• Can manage complex caseloads and competing priorities
• Is a strong leader and team collaborator
• Is proactive, resourceful, and solution-oriented
• Thrives in fast-paced, community-based environments
• Enjoys engaging with the community and building relationships
• Is passionate about supporting high-acuity, underserved populations
• Detail-Oriented and enjoys multi tasking
• Embraces constructive feedback
• Proficient with high-volume documentation and enjoys keeping meticulous, complete records of every member touchpoint.
• Comfortable and compassionate when working with complex individuals facing severe mental health challenges, and demonstrates strong emotional intelligence and proven de-escalation techniques during crisis situations.

Equal Employment Opportunity

Pacific Health Group, along with its divisions, is a proud Equal Opportunity Employer. We embrace diversity and are devoted to creating an inclusive environment for all employees. Our commitment is to ensure equal employment opportunities for every qualified candidate, irrespective of race, religion, gender, sexual orientation, gender identity, age, national origin, citizenship, disability, marital status, veteran status, or any other status protected by federal, state, or local laws. At Pacific Health Group, we recognize the importance of accessibility and are dedicated to providing reasonable accommodations for individuals with disabilities. We believe that our strength lies in our diversity, and we are committed to building a workforce that reflects the varied communities we serve. Join us in a workplace where everyone's contributions are valued and respected.

Pre-Employment Requirements

Employment is contingent upon the successful completion of our pre-employment process, which includes a background check and the submission of all required documentation and new hire paperwork.

AI & Human Interaction (HI) in Recruitment

Pacific Health Group is committed to fairness, equity, and transparency in our hiring practices. We use AI (Artificial Intelligence) tools to help match candidate resumes against our job descriptions, focusing on qualifications, skillsets, and location. All resumes that meet these criteria are then reviewed by HI (Human Interaction) our recruiting and HR team. Pacific Health Group remains true to our Equal Employment Opportunity (EEO) statement, ensuring that every candidate is given fair and consistent consideration.