Community Supports Lead Care Coordinator Shasta

Job Title

At Pacific Health Group, we are at the forefront of 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.

This is a highly field-based role supporting members directly in the community.

• 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 inspections, 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.
• This role requires independence, strong time management, leadership capability, and comfort working in fast-paced, community-based environments.

Housing Stability Services

• 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.

Care Coordination & Case Management

• 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

Member Engagement & Advocacy

• 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

Community Outreach & Engagement

• 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

Community Resource Navigation

• 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

Team Support

• 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

Documentation & Compliance

• 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

Team Collaboration

• Partner with interdisciplinary teams including behavioral health, outreach, and social services
• Coordinate with healthcare providers and payers to ensure seamless care delivery

Continuous Improvement

• Identify trends and gaps in services
• Demonstrate a high level of…