Community Supports Lead Care Coordinator (Housing)

United States·SacramentoFull-timelead

Care CoordinatorHealthcare Non-Clinical

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Requirements Summary

1 coaching syncs to integrate feedback and refine daily workflows. How Success Is Measure

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Care CoordinatorHealthcare Non-Clinical

What We Offer

~2 min read

✓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 (including individuals experiencing severe mental health conditions and substance dependencies).

✓Spend 30–50% of your time in the field — delivering face-to-face case management across shelters, community settings, and residences. This includes conducting in-person housing assessments, unit habitability inspections, and active member outreach.

✓Travel locally within the county and surrounding counties, including Marin, Napa, Solano, Sonoma, and Santa Cruz Counties

✓Manage and coordinate the application pipeline for housing resources, including processing critical documents like Housing Deposit Services (HDS) packages by gathering required documentation to facilitate access to deposit assistance that removes financial barriers to securing permanent housing 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.

✓Manage a dynamic caseload of 60–70 members experiencing chronic housing instability, executing end-to-end care coordination, housing barrier mitigation, and persistent outreach.

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

✓Hourly Range:$30.00 - $35.00, depending on experience, qualifications, and internal equity

✓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

Responsibilities

~1 min read

→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.
→Possess the operational capacity and organizational skills to execute all aspects of member management—including high-volume telephonic/field outreach, initial intake assessments, care plan development, ongoing monthly touchpoints, and crisis escalation—while maintaining compliance and documentation standards.

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
Support outreach efforts that drive member engagement and program awareness

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
Demonstrate a high level of professionalism by actively collaborating with leadership during 1:1 coaching syncs to integrate feedback and refine daily workflows.

Successful housing placements and housing retention for eligible members.
Demonstrated continuous progression of member care through the care pipeline. This includes maintaining strong engagement with high-needs individuals, avoiding gaps in care, and successfully helping members meet their housing stabilization milestones.
Timely coordination of Housing Transition Navigation Services, Housing Tenancy & Sustaining Services, and Housing Deposit assistance.
Improved member health outcomes through housing stabilization and reduced barriers to care.
Member engagement and successful care coordination outcomes
Timely and accurate documentation
Ability to manage caseload independently and effectively, and keeping your caseload active and continuously growing through effective outreach and timely enrollment strategies.
Quality team support provided
Strength of community partnerships and outreach engagement
Compliance with program and regulatory requirements

Is comfortable working independently in the field and remote environments
Can manage complex caseloads and competing priorities
Is a strong leader and team collaborator
Is proactive, resourceful, and solution-oriented
Thrives in fast-paced, community-based environments
Enjoys engaging with the community and building relationships
Is passionate about supporting high-acuity, underserved populations
Detail-Oriented and enjoys multi tasking
Embraces constructive feedback
Proficient with high-volume documentation and enjoys keeping meticulous, complete records of every member touchpoint.
Comfortable and compassionate when working with complex individuals facing severe mental health challenges, and demonstrates strong emotional intelligence and proven de-escalation techniques during crisis situations.

Requirements

~1 min read

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