This role is a high-impact, field-based position supporting members in the community by addressing social determinants of health and providing community-based services. As a Lead Care Coordinator, you will guide members at every step, arranging needed services and building trusting relationships. You will respond to real-life challenges such as housing, food insecurity, and mental health, ensuring comprehensive support.
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 the 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
Build relationships with community-based organizations
Identify gaps in resources and escalate when needed
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
Requirements
Reside in hiring county
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
Valid California Driver’s License and active auto insurance meeting CA requirements
Millions of jobs, with real people getting hired every day
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Verified job listings
1,000,000+
Tailored applications submitted
Reliable personal vehicle for daily work use
Successful completion of background check (including MVR)
Ability to travel up to 60-70% within the county to conduct in person visits
Successfully complete a Testlify skills assessment
Reliable working laptop for the first 21 days of employment (personal equipment stipend) until company issues laptop is received
Effective Time Management skills
Internet speed of 300+ mbps download and 25+ mbps upload
Proficient in technology, including documentation systems, case management platforms, and communication tools
Comfortable working independently in the field
Ability to manage a high caseload independently with minimal supervision
Resourceful, proactive, and solution-oriented
Thrives in fast-paced, community-based environments
Passionate about supporting underserved populations
Cares about their community and its people
Independently navigate new software and company issued equipment
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.
About the Company
At Pacific Health Group, we are a catalyst for positive change in our communities. Our Enhanced Care Management (ECM) programs focus on addressing social determinants of health and providing community-based services that truly meet each individual’s needs.
