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

Community Supports Program Role

Schedule: Monday Friday | 8:30 AM 5:00 PM

Compensation: $30.00 $35.00 per hour

Location: Hybrid (Sonoma County, Napa County, Solano County)

FLSA Status: Non-Exempt

This position is an individual contributor, not a People Manager.

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 plansyou'll guide members through every step of their journey, ensuring they receive the support and services needed to thrive.

This is a highly field-based role supporting members directly in the community.

• Manage a caseload of members with complex health and social needs
• Spend approximately 65% of your time in the field (homes, shelters, community settings)
• Conduct in-person visits, assessments, and follow-ups
• Travel locally within hiring county
• Coordinate services across healthcare, behavioral health, and community resources
• Participate in community outreach efforts including events, partnerships, and local engagement
• Provide mentorship and support to other care managers
• Document in real-time or by end of day using internal systems

This role requires independence, strong time management, leadership capability, and comfort working in fast-paced, community-based environments.

Care Coordination & Case Management

• Conduct comprehensive member assessments to identify health and social needs
• Develop and manage individualized care plans
• Coordinate appointments, services, and long-term 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, food access, workforce programs, childcare, and other services
• Strengthen partnerships with community-based organizations
• Identify gaps in resources and escalate needs for program improvement

Leadership & Team Support

• Provide guidance, mentorship, and support to care managers within the program
• Assist with onboarding and training of new team members
• 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
• Provide feedback to leadership to improve care coordination strategies and partnerships

How Success Is Measured

• Member engagement and successful care coordination outcomes
• Timely and accurate documentation
• Ability to manage caseload independently and effectively
• Quality of mentorship and 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
• 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

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.

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.

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.