Community Supports Lead Care Coordinator (Housing)

Pacific Health Group•Fresno, CA

3d•Hybrid

About The Position

Pacific Health Group is hiring a Community Supports Lead Care Coordinator for its Medi-Cal Community Supports Program, which helps members address health-related social needs and live more independently. The role focuses on housing stability for members who are unhoused or at risk of homelessness, including delivery and coordination of Housing Transition Navigation Services, Housing Tenancy & Sustaining Services, and Housing Deposit assistance. The coordinator manages a caseload of approximately 60–70 members and provides comprehensive, person-centered care management. Work includes outreach, intake and needs assessments, individualized care planning, housing-resource applications, coordination with healthcare and community services, persistent follow-up, and crisis escalation. The role works with high-needs members, including people experiencing severe mental health conditions or substance dependencies, and requires compassionate engagement and de-escalation skills. This is a highly field-based position with a hybrid arrangement described as California remote with occasional fieldwork. Field duties may include face-to-face case management at shelters, community settings, and residences, as well as in-person housing assessments, unit habitability inspections, and active member outreach. The coordinator also builds relationships with housing providers, shelters, landlords, property managers, housing authorities, healthcare providers, and community organizations; participates in community outreach; supports team collaboration and peer shadowing; and maintains timely, accurate documentation in compliance with Medi-Cal, CalAIM, and Community Supports requirements. The schedule is Monday through Friday, 8:30 AM to 5:00 PM. The position is non-exempt and pays $29.00–$33.00 per hour, depending on experience, qualifications, and internal equity. Travel within the hiring county and surrounding counties is required.

Requirements

Strong understanding of the housing system and 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 care coordination, housing navigation, or case management.
Strong understanding of healthcare systems, managed care, and community resources.
Excellent communication, empathy, and cultural competence.
Strong organizational and time-management skills, with the ability to manage complex caseloads and competing priorities.
Proficiency with technology, including case management systems, EHR platforms, documentation tools, and multiple communication platforms.
Ability to document in real time and manage member data accurately.
Comfort and compassion when working with complex individuals experiencing severe mental health challenges; strong emotional intelligence and proven de-escalation techniques during crises.
Ability to work independently in field and remote environments and in fast-paced, community-based settings.
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.

Nice To Haves

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

Responsibilities

Support members experiencing homelessness or at risk of homelessness with Housing Transition Navigation Services and transitions into long-term stable housing.
Coordinate Housing Tenancy & Sustaining Services, including ongoing case management, advocacy, landlord engagement, and connections to healthcare, behavioral health, and community resources.
Assist members with Housing Deposit services by gathering and processing required documentation and coordinating landlord allocations.
Conduct telephonic outreach, comprehensive intakes, member assessments, housing assessments, and ongoing follow-up.
Manage a caseload of approximately 60–70 members, including care planning, monthly touchpoints, high-volume outreach, and crisis escalation.
Develop and manage individualized housing care plans based on members’ health and social needs.
Coordinate appointments, services, and long-term housing support systems to promote continuity of care.
Provide phone, video, and in-person support and advocate for timely care, services, and equitable access to resources.
Conduct field-based case management at shelters, community settings, and residences; perform unit habitability inspections and active outreach as needed.
Collaborate with housing authorities, landlords, shelters, property managers, healthcare providers, and community-based organizations to support housing placement and tenancy.
Monitor members’ housing stability and proactively address barriers that may put housing or health outcomes at risk.
Represent Pacific Health Group at community outreach events and initiatives, build referral routes, and strengthen community partnerships.
Identify community resource gaps and escalate needs for program improvement.
Maintain accurate, timely, real-time documentation of member interactions, progress, outcomes, and services in accordance with Medi-Cal, CalAIM, and Community Supports requirements.
Partner with interdisciplinary teams, including behavioral health, outreach, social services, healthcare providers, and payers.
Participate in departmental huddles, share housing resources with the team, provide cross-coverage support, and assist with shadowing sessions for new Lead Care Managers.
Collaborate with leadership during coaching syncs, incorporate feedback, and refine daily workflows.
Maintain an active and growing caseload through effective outreach and timely enrollment strategies.