Community Supports Lead Care Coordinator (Housing)

Pacific Health Group•Riverside, CA

3d•Hybrid

About The Position

Pacific Health Group is hiring a Community Supports Lead Care Coordinator to support Medi-Cal members experiencing homelessness or housing instability through CalAIM Community Supports housing programs. The role provides person-centered care coordination, housing navigation, tenancy-sustaining support, and housing deposit assistance to help members secure and maintain stable housing while addressing related health and social needs. The position is hybrid, based remotely in California, with mandatory occasional fieldwork and travel within the hiring county and surrounding counties. The schedule is Monday through Friday, 8:30 AM to 5:00 PM, and compensation is $29.00–$33.00 per hour. The coordinator manages a high-needs caseload of approximately 60–70 members, including individuals experiencing severe mental health conditions and substance dependencies. Work includes telephonic outreach, comprehensive intakes and assessments, individualized care planning, ongoing member engagement, crisis escalation, housing applications and documentation, and coordination with healthcare and community-based services. Fieldwork may include face-to-face case management at shelters, community settings, and residences, as well as housing assessments and unit habitability inspections. The role also builds partnerships with housing providers, landlords, shelters, housing authorities, healthcare providers, and community organizations; participates in outreach events; supports team collaboration and peer coverage; and maintains accurate, timely documentation in accordance with Medi-Cal, CalAIM, and Community Supports requirements. Success is measured by housing placements and retention, member engagement and progress, timely service coordination, documentation quality, caseload management, team support, community partnerships, and regulatory compliance.

Requirements

Strong understanding of the housing system and working knowledge of local housing resources, housing navigation, community-based support programs, or transitional housing workflows.
Three to five 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.
Strong 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, accurately manage member data, and navigate 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.
Ability to work independently in remote and field environments and manage complex caseloads and competing priorities.
Comfort and compassion when working with individuals facing severe mental health challenges, with strong emotional intelligence and demonstrated crisis de-escalation skills.

Nice To Haves

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

Responsibilities

Support members experiencing homelessness or at risk of homelessness through Housing Transition Navigation Services.
Coordinate Housing Tenancy & Sustaining Services, including ongoing case management, advocacy, landlord engagement, and connections to healthcare, behavioral health, and community resources.
Coordinate Housing Deposit assistance, gather required documentation, and facilitate access to deposit support.
Conduct telephonic outreach, comprehensive intakes, member assessments, and in-person housing assessments as needed.
Provide face-to-face case management in shelters, community settings, and residences, including unit habitability inspections and active outreach.
Manage an active caseload of approximately 60–70 members, including outreach, enrollment, care planning, monthly touchpoints, crisis escalation, and follow-through.
Develop and manage individualized housing care plans and coordinate appointments, services, and long-term housing support.
Collaborate with housing authorities, landlords, shelters, property managers, healthcare providers, payers, and community-based organizations to support housing placement and tenancy.
Monitor housing stability and proactively address barriers that could jeopardize housing or health outcomes.
Build and maintain community partnerships, participate in outreach events, and identify opportunities to improve access and program awareness.
Connect members to housing and other community resources, identify resource gaps, and escalate needs for program improvement.
Maintain accurate, timely, real-time documentation of member interactions and service delivery in compliance with Medi-Cal, CalAIM, and Community Supports requirements.
Track member progress, outcomes, and service delivery.
Collaborate with interdisciplinary teams, including behavioral health, outreach, and social services.
Participate in departmental huddles, share housing resources, provide cross-coverage, and assist with shadowing sessions for new Lead Care Managers.
Collaborate with leadership during coaching sessions, incorporate feedback, and refine workflows.
Travel within the hiring county and surrounding counties for fieldwork.