Community Support Lead Care Coordinator (Housing)

Pacific Health Group•San Francisco, CA

1d•Hybrid

About The Position

Pacific Health Group is hiring a Community Support Lead Care Coordinator for its Community Supports Program, which helps Medi-Cal members live more independently by addressing health-related social needs. This highly field-based role supports members in CalAIM Community Supports housing programs, including Housing Transition Navigation Services, Housing Tenancy & Sustaining Services, and Housing Deposit assistance. The coordinator provides person-centered housing care management to a diverse, high-needs caseload, including members experiencing severe mental health conditions and substance dependencies. The role includes telephonic outreach, comprehensive intakes, housing assessments, unit habitability inspections, member outreach, and in-person case management in shelters, community settings, and residences. Approximately 30–50% of the role is spent in the field, with local travel within the hiring county and surrounding counties, including Marin, Napa, Solano, Sonoma, and Santa Cruz Counties. The coordinator manages a caseload of approximately 60–70 members experiencing chronic housing instability. Responsibilities span end-to-end care coordination, individualized care planning, housing barrier mitigation, persistent outreach, service and appointment coordination, crisis escalation, housing-resource applications, and coordination of Housing Deposit Services documentation and landlord allocations. The role also requires developing partnerships with housing providers, shelters, landlords, property managers, healthcare providers, and community organizations; participating in community outreach; and maintaining accurate, timely, high-fidelity documentation in multiple platforms in accordance with program and regulatory requirements. The position requires independence, leadership capability, strong organization and time management, and comfort working in fast-paced community-based and remote environments. The schedule is Monday through Friday, 8:30 AM–5:00 PM. The role is hybrid in California within the hiring county and is classified as non-exempt. Compensation is $30.00–$35.00 per hour, depending on experience, qualifications, and internal equity. Employment is contingent on completing the pre-employment process, including a background check and submission of required documentation and new-hire paperwork.

Requirements

Strong understanding of the housing system and demonstrated 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.
3–5 years of experience in case management, social services, or healthcare.
Experience independently managing an active caseload in a care coordination, housing navigation, or case management environment.
Strong understanding of healthcare systems, managed care, and community resources.
Excellent communication, empathy, and cultural competence.
Strong organizational and time-management skills.
Proficiency with technology, including case management systems, EHR platforms, and documentation tools.
Ability to document in real time and manage member data accurately across multiple systems and communication platforms.
Ability to travel within the hiring county and surrounding counties.
Valid California Driver’s License and active auto insurance meeting California requirements.
Reliable personal vehicle for daily work use.
Comfort and compassion working with complex individuals facing severe mental health challenges, with strong emotional intelligence and proven de-escalation techniques during crisis situations.
Ability to work independently in field and remote environments, manage complex caseloads and competing priorities, collaborate as a leader and team member, and maintain meticulous documentation.

Nice To Haves

Experience with Medi-Cal, CalAIM, and Community Supports programs (listed as preferred).

Responsibilities

Support members experiencing homelessness or at risk of homelessness through Housing Transition Navigation Services and coordination of healthcare and community-based services.
Coordinate Housing Tenancy & 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 required documentation and facilitating access to deposit assistance.
Collaborate with housing authorities, landlords, shelters, property managers, healthcare providers, and community-based organizations to support housing placement and long-term tenancy.
Monitor members’ housing stability and proactively address barriers that could put housing or health outcomes at risk.
Conduct high-volume telephonic and field outreach, initial intake assessments, care-plan development, monthly touchpoints, and crisis escalation while maintaining compliance and documentation standards.
Conduct comprehensive assessments of members’ health and social needs and develop and manage individualized housing care plans.
Coordinate appointments, services, and long-term housing support systems to ensure continuity of care and consistent follow-through.
Build trusting relationships with members and families and provide support through phone, video, and in-person visits.
Advocate for timely care, services, and equitable access to resources.
Represent Pacific Health Group at community outreach events, partnerships, and local initiatives; build relationships with community-based organizations, shelters, and service providers; and identify opportunities to improve access and program awareness.
Connect members to housing resources, strengthen community-based partnerships, and identify resource gaps for escalation and program improvement.
Participate in departmental huddles, share housing resources with the team, provide cross-coverage support, and assist with shadowing sessions for new Lead Care Managers.
Maintain accurate and timely documentation of member interactions and comply with Medi-Cal, CalAIM, and Community Supports requirements; track progress, outcomes, and service delivery.
Partner with interdisciplinary teams, including behavioral health, outreach, and social services, and coordinate with healthcare providers and payers.
Identify service trends and gaps and collaborate with leadership during coaching sessions to incorporate feedback and refine workflows.
Manage a caseload of approximately 60–70 members, maintaining engagement, continuous progression through the care pipeline, and timely enrollment and outreach.
Travel within the hiring county and surrounding counties for field work.