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About the Role

Pacific Health Group is revolutionizing health and wellness through innovation, compassion, and community-driven care. Our Community Supports (CS) Program helps Medi-Cal members live more independently by addressing health-related social needs. In this role, you will guide members through every step of their journey, ensuring they receive the support and services needed to thrive.

Responsibilities

Support members participating in CalAIM Community Supports Housing programs, including Housing Transition Navigation Services, Housing Tenancy & Sustaining Services, and Housing Deposit assistance.
Conduct telephonic outreach and complete comprehensive intakes to identify housing needs of those who are unhoused or at risk of homelessness.
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.
Spend 30–50% of your time in the field — delivering face-to-face case management across shelters, community settings, and residences.
Manage and coordinate the application pipeline for housing resources, including processing critical documents like Housing Deposit Services (HDS) packages.
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.
Manage a dynamic caseload of 60–70 members experiencing chronic housing instability, executing end-to-end care coordination, housing barrier mitigation, and persistent outreach.
Support members experiencing homelessness or at risk of homelessness by providing Housing Transition Navigation Services.
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.
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 individualized housing 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.
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.
Actively collaborating with leadership during 1:1 coaching syncs to integrate feedback and refine daily workflows.

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).
Experience: 3-5 years in case management, social services, or healthcare
Experience with: Medi-Cal, CalAIM, and Community Supports programs (preferred)
Experience independently managing an active caseload in a care coordination, housing navigation, or case management environment.
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 within hiring county and surrounding counties
Valid California Driver's License and active auto insurance meeting CA requirements
Reliable personal vehicle for daily work use
Employment is contingent upon the successful completion of our pre-employment process, which includes a background check and the submission of all required documentation and new hire paperwork.

Skills

Housing Transition Navigation Services
Housing Tenancy & Sustaining Services
Housing Deposit assistance
Telephonic outreach
Comprehensive intakes
Housing needs assessment
Partnership building
Person-centered care management
Field-based case management
Housing assessments
Unit habitability inspections
Member outreach
Application pipeline management
Community outreach
Platform navigation
Chart notes
Clinical documentation
Caseload management
Care coordination
Housing barrier mitigation
Outreach
Care plan development
Monthly touchpoints
Crisis escalation
Compliance
Documentation standards
Housing placement
Long-term tenancy
Member engagement
Advocacy
Community resource navigation
Team collaboration
Cross-coverage support
Shadowing
Best practices
Medi-Cal compliance
CalAIM compliance
Community Supports program compliance
Outcome tracking
Service delivery tracking
Interdisciplinary team collaboration
Healthcare provider coordination
Payer coordination
Trend identification
Gap identification
Leadership
1:1 coaching
Feedback integration
Workflow refinement
Housing placements
Housing retention
Member care progression
High-needs engagement
Care pipeline management
Housing stabilization milestones
Member health outcomes
Care coordination outcomes
Documentation accuracy
Independent caseload management
Effective outreach
Enrollment strategies
Team support quality
Community partnership strength
Outreach engagement strength
Program and regulatory compliance
Independent work
Remote work
Complex caseload management
Competing priorities management
Leadership capability
Team collaboration
Proactiveness
Resourcefulness
Solution-orientation
Fast-paced environment adaptation
Community engagement
Relationship building
High-acuity population support
Underserved population support
Detail-orientation
Multitasking
Constructive feedback reception
High-volume documentation
Meticulous record keeping
Compassionate work with complex individuals
Severe mental health challenge support
Emotional intelligence
De-escalation techniques
Crisis situation management
Technology proficiency
Case management systems
EHR platforms
Documentation tools
Real-time documentation
Member data management
System navigation
Communication platform navigation
Travel
California Driver's License
Auto insurance
Personal vehicle use

Location

Hybrid CA (Within hiring county)
Marin County
Napa County
Solano County
Sonoma County
Santa Cruz County

Work Type

Hybrid
Field-based
Non-Exempt

Experience Level

3-5 years in case management, social services, or healthcare
Experience independently managing an active caseload

Salary/Compensations

$30.00 – $35.00 per hour

Benefits

Monthly stipend
Mileage Reimbursement
160 hours PTO + paid sick time
11 paid holidays (including birthday and floating holiday)
4 paid volunteer hours per month
90% employer-paid employee-only medical benefits
Flexible Spending Account (FSA)
Short-term & long-term disability, AD&D
Employee Assistance Program (EAP)
401(k) with company match
Professional development opportunities
Quarterly in-person events
Employee discount programs

About the Company

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.

Equal Opportunity

Pacific Health Group, along with its divisions, is a proud Equal Opportunity Employer.
We embrace diversity and are devoted to creating an inclusive environment for all employees.
Our commitment is to ensure equal employment opportunities for every qualified candidate, irrespective of race, religion, gender, sexual orientation, gender identity, age, national origin, citizenship, disability, marital status, veteran status, or any other status protected by federal, state, or local laws.
At Pacific Health Group, we recognize the importance of accessibility and are dedicated to providing reasonable accommodations for individuals with disabilities.
We believe that our strength lies in our diversity, and we are committed to building a workforce that reflects the varied communities we serve.
Join us in a workplace where everyone's contributions are valued and respected.