Community Supports Lead Care Coordinator (Housing) - Mendocino County

What This Role Looks Like (Day-to-Day Reality)

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.

What You’ll Do

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 professionalism by actively collaborating with leadership during 1:1 coaching syncs to integrate feedback and refine daily workflows.

How Success Is Measured

• 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.

Who Thrives in This Role

• 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.