Community Supports Lead Care Coordinator (Housing) - Santa Cruz County

Job TitleThis position is an individual contributor, not a People Manager.Job DescriptionAt 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.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 housingBuild 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-upsTravel locally within county and surrounding countiesManage 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 ServicesSupport 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 ManagementConduct comprehensive member assessments to identify health and social needs.Develop and manage housing individualized care plansCoordinate appointments, services, and long-term housing support systemsEnsure continuity of care and consistent follow-throughMember Engagement & AdvocacyBuild strong, trusting relationships with members and their familiesProvide ongoing support through phone, video, and in-person visitsAdvocate for timely care, services, and equitable access to resourcesCommunity Outreach & EngagementRepresent Pacific Health Group in the community through outreach events, partnerships, and local initiativesBuild and maintain relationships with community-based organizations, shelters, and service providersIdentify opportunities to expand community presence and improve access to servicesSupport outreach efforts that drive member engagement and program awarenessCommunity Resource NavigationConnect members to housing resources and assist providing long term housingStrengthen partnerships with community-based organizationsIdentify gaps in resources and escalate needs for program improvementTeam SupportActively 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 sessionsPromote consistency, collaboration, and best practices across the teamDocumentation & ComplianceMaintain accurate and timely documentation of all member interactionsEnsure compliance with Medi-Cal, CalAIM, and Community Supports program requirementsTrack progress, outcomes, and service deliveryTeam CollaborationPartner with interdisciplinary teams including behavioral health, outreach, and social servicesCoordinate with healthcare providers and payers to ensure seamless care deliveryContinuous ImprovementIdentify trends and gaps in servicesDemonstrate 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 MeasuredSuccessful 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 outcomesTimely and accurate documentationAbility to manage caseload independently and effectively, and keeping your caseload active and continuously growing through effective outreach and timely enrollment strategies.Quality team support providedStrength of community partnerships and outreach engagementCompliance with program and regulatory requirementsWho Thrives in This RoleIs comfortable working independently in the field and remote environmentsCan manage complex caseloads and competing prioritiesIs a strong leader and team collaboratorIs proactive, resourceful, and solution-orientedThrives in fast-paced, community-based environmentsEnjoys engaging with the community and building relationshipsIs passionate about supporting high-acuity, undeserved populationsDetail-Oriented and enjoys multi taskingEmbraces constructive feedbackProficient with high-volume documentation and enjoys keeping meticulous, complete records of every member touch point.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 OpportunityPacific 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 RequirementsEmployment 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 RecruitmentPacific Health Group is committed to fairness, equity, and transparency in our hiring practices. We use AI