Solano County

Pacific Health Group•American Canyon, CA

6d•$30 - $35•Hybrid

About The Position

Pacific Health Group is 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.

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 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

Nice To Haves

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

Responsibilities

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 inpections, 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.
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.
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.
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 resources and assist providing long term housing.
Strengthen partnerships with community-based organizations.
Identify gaps in resources and escalate needs for program improvement.
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.
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.
Demonstrate a high level of professionalism by actively collaborating with leadership during 1:1 coaching syncs to integrate feedback and refine daily workflows.