Lead Care Coordinator

Responsibilities

• Manage a caseload of approximately 60-70 members
• Conduct 3-5 in-person visits per day (homes, shelters, community settings)
• Spend 60-70% of your time in the field
• Travel locally within hiring county (mileage reimbursed)
• Coordinate care across medical, behavioral health, and community services
• Document in real-time or by end of day using internal systems
• Develop and manage individualized care plans
• Coordinate appointments, services, and follow-ups across providers
• Support transitions of care (hospital discharge, referrals, etc.)
• Build trust through consistent, in-person engagement
• Advocate for timely access to care, services, and resources
• Support members navigating housing, food access, transportation, and behavioral health needs
• Represent Pacific Health Group in the community through outreach events, partnerships, and local initiatives
• Build and maintain relationships with community-based organizations, shelters, and local resource partners
• Identify opportunities to expand community presence and improve member access to services
• Connect members to local programs and services
• Complete timely and accurate documentation
• Maintain compliance with Medi-Cal, CalAIM, and ECM program requirements
• Partner with internal teams, providers, and community stakeholders
• Participate in case conferences and care coordination meetings

• Residency:
  Must reside in hiring county
• Experience:
  
  3–5 years in case management, social services, or healthcare (preferred)
• Experience with:
  Medi-Cal, CalAIM, or Enhanced Care Management (preferred)
• Working experience of healthcare systems and community resources is a plus
• Excellent communication, organization, and time management skills
• Proficiency with documentation systems and technology
• Ability to effectively communicate both written and verbally