Solano County

Pacific Health Group•Santa Rosa, CA

9d•$30 - $35•Hybrid

About The Position

Pacific Health Group is seeking a Community Support Lead Care Coordinator to join their team. This role is focused on helping Medi-Cal members live more independently by addressing health-related social needs. The Care Coordinator will guide members through their journey, ensuring they receive the necessary support and services. This is a highly field-based role, requiring approximately 65% of time spent in the community, conducting in-person visits, assessments, and follow-ups. The position involves managing a caseload of members with complex health and social needs, coordinating services across various sectors, and participating in community outreach. The role requires independence, strong time management, leadership capability, and comfort in fast-paced, community-based environments.

Requirements

3–5 years in case management, social services, or healthcare
Strong understanding of healthcare systems, managed care, and community resources
Excellent communication, empathy, and cultural competence
Strong organizational and time management skills
Must be proficient in technology, including case management systems, EHR platforms, and documentation tools
Ability to document in real-time and manage member data accurately
Comfortable navigating multiple systems and communication platforms
Ability to travel locally within hiring county
Valid California Driver's License and active auto insurance meeting CA requirements
Reliable personal vehicle for daily work use
Successful completion of background check (including MVR)
Must be able to travel up to 60-70% within the county to conduct in person visits
Must successfully complete a Testlify skills assessment
Must have a reliable working laptop for the first 21 days of employment (personal equipment stipend) until company issued laptop is received
Must have effective Time Management skills
Must have internet speed of - 300+ mbps download and 25+mbps upload
Must be proficient in technology, including documentation systems, case management platforms, and communication tools

Nice To Haves

Experience with: Medi-Cal, CalAIM, and Community Supports programs

Responsibilities

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.
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.
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.
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.
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.
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.
Partner with interdisciplinary teams including behavioral health, outreach, and social services.
Coordinate with healthcare providers and payers to ensure seamless care delivery.
Identify trends and gaps in services.
Provide feedback to leadership to improve care coordination strategies and partnerships.