Pacific Health Group

Care Coordinator

• 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.

Community Supports Lead Care Coordinator – Housing

Patient Coordinator

• Responsible for answering, returning, and scheduling client calls promptly and professionally.
• Implement a screening and triage process to assist potential patients in determining the necessary services.
• Complete all data entry for pre-admission including identifying information, the reason for referral, relevant history, and insurance information.
• Verify patient health insurance eligibility, benefits, and pre-authorizations accurately prior to appointments.
• Utilize the ability to add, update, and edit scheduling services to maximize clinic efficiency.
• Identify emergent or complex cases and seek clinical review, as needed, prior to finalizing the patient's appointment.
• Maintain a positive working relationship with managerial, administrative, and clinical staff to assure efficiency in the day-to-day responsibilities.
• Work closely with healthcare providers to monitor patient attendance, troubleshoot barriers to care, and ensure a seamless patient experience.
• Maintain confidentiality of all clinical and administrative information consistent with company policy and HIPAA guidelines.
• Represent the organization in local communities to raise awareness of our services and connect individuals to care.
• Plan, coordinate, and staff community health fairs, cultural events, and tabling opportunities.
• Performs other duties as assigned to support the growth and needs of the department.

Patient Engagement Coordinator

Administration

• Oversee the monthly and quarterly submission of Enhanced Care Management (ECM) Report Template Files (RTF) and Outreach Transmission Files (OTF) to all contracted health plans.
• Gather, validate, and consolidate data from multiple internal systems, ensuring accuracy of member demographics, service dates, and case notes.
• Ensure all submissions meet health plan-specific formatting and regulatory requirements to maintain compliance.
• Conduct recurring eligibility checks to confirm members remain qualified for ECM, Medi-Cal, and other service programs.
• Partner with case managers to reassess member needs and adjust service enrollments accordingly.
• Document all re-qualification activities in compliance with audit standards and payer expectations.
• Maintain a consolidated and reliable view of all member touchpoints by duplicating Lead Care Manager (LCM) notes from TheraPlatform into SalesMate.
• Produce recurring weekly and monthly reports to monitor organizational performance and compliance.

Data Administrator

Billing Specialist

• Prepare, scrub, and submit daily bundled rate claims for Clubhouse Services through the County of San Diego's designated claiming system/EHR and ShortDoyle/MediCal process, in accordance with County and DHCS requirements.
• Apply correct procedure codes, modifiers, place-of-service, and rendering/billing provider data per BHIN 25009, the BH-CONNECT EBP Policy Guide, and County billing manuals.
• Reconcile daily Clubhouse attendance logs and service documentation against claimable member days before submission; flag undocumented or unsupported days to program leadership prior to claiming.
• Track and comply with timely filing requirements and County claim submission calendars.
• Verify MediCal eligibility and aid codes for all Clubhouse members monthly (and prior to claiming), including share-of-cost, other health coverage (OHC), and managed care assignment issues that affect SMHS claiming.
• Coordinate resolution of eligibility discrepancies with program staff and County BHS as needed.
• Work claim denials, disallowances, and voids/replacements; perform root-cause analysis and correct/resubmit within required timeframes.
• Reconcile remittances (835s/EOBs) against submitted claims; maintain accurate accounts receivable aging and escalate underpayments or unpaid claims.
• Prepare monthly revenue reconciliation reports (claimed vs. paid vs. expected at the County bundled rate) for leadership.
• Maintain working knowledge of BHCONNECT Clubhouse Services requirements, including the daily bundled rate structure, medical necessity/eligibility criteria, and documentation standards; monitor DHCS BHINs and County BHS updates for claiming changes.
• Understand the Clubhouse International Accreditation requirement and its impact on claiming eligibility (MediCal claiming is limited to four years total prior to Accreditation); support leadership in tracking accreditation-linked billing status.
• Support internal charter-claim audits and respond to County/DHCS audit requests, recoupments, and cost report or data submissions as assigned.
• Ensure all billing activity complies with HIPAA, 42 CFR Part 2 (where applicable), and MediCal program integrity requirements; report suspected compliance issues immediately.
• Serve as the billing liaison to County of San Diego BHS billing/fiscal contacts for Clubhouse Services claiming questions.
• Train Clubhouse program staff on documentation elements required to support the daily bundled rate.
• Assist with billing workflow buildout, desk procedures, and QA processes for this new service line; support billing for other PHG lines of business as capacity allows.

Billing Analyst

Therapist

• Deliver direct and telehealth therapy services to clients via phone, video, and in-person.
• Provide crisis intervention and short- and long-term psychotherapy.
• Conduct mental health evaluations and formulate treatment plans.
• Offer referrals and case management services.
• Maintain up-to-date, accurate clinical records in compliance with HIPAA.
• Ensure all documentation is completed within established deadlines.
• Adhere to mandated reporting protocols.
• Engage with case management, administrative, and leadership teams to ensure coordinated care.
• Maintain professional, timely communication via email, phone, and instant messaging.
• Participate in team meetings, trainings, and interdisciplinary planning.
• Work independently with minimal supervision.
• Demonstrate punctuality, reliability, and responsiveness.
• Uphold a high standard of customer service and empathy.
• Collaborative work with case management team, administrative team, and management team.
• Participate in clinical supervision and maintains supervision log.
• Provide continuing clinical assessment, treatment planning, and clinical treatment for patients and families.

Associate Therapist – ECM Consultant

• Manage a caseload of members with complex health and social needs
• Spend approximately 65% of your time in the field (homes, shelters, community settings)
• Conduct in-person visits, assessments, and follow-ups
• Travel locally within hiring county
• Coordinate services across healthcare, behavioral health, and community resources
• Participate in community outreach efforts including events, partnerships, and local engagement
• Provide mentorship and support to other care managers
• Document in real-time or by end of day using internal systems
• Conduct comprehensive member assessments to identify health and social needs
• Develop and manage individualized care plans
• Coordinate appointments, services, and long-term 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, food access, workforce programs, childcare, and other services
• Strengthen partnerships with community-based organizations
• Identify gaps in resources and escalate needs for program improvement
• Provide guidance, mentorship, and support to care managers within the program
• Assist with onboarding and training of new team members
• 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
• Provide feedback to leadership to improve care coordination strategies and partnerships

Community Support Lead Care Coordinator

• Manage a caseload of members with complex health and social needs
• Spend approximately 65% of your time in the field (homes, shelters, community settings)
• Conduct in-person visits, assessments, and follow-ups
• Travel locally within hiring county
• Coordinate services across healthcare, behavioral health, and community resources
• Participate in community outreach efforts including events, partnerships, and local engagement
• Provide mentorship and support to other care managers
• Document in real-time or by end of day using internal systems
• Conduct comprehensive member assessments to identify health and social needs
• Develop and manage individualized care plans
• Coordinate appointments, services, and long-term 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
• Identify opportunities to expand community presence and improve access to services
• Connect members to housing, food access, workforce programs, childcare, and other services
• Strengthen partnerships with community-based organizations
• Provide guidance, mentorship, and support to care managers within the program
• Maintain accurate and timely documentation of all member interactions
• Ensure compliance with Medi-Cal, CalAIM, and Community Supports program requirements

Community Support Lead – Care Coordinator

Advisor

• Our Street Outreach Advisors work directly in the community to connect individuals with the care and support services that improve health and stability.
• Through in-person outreach and strong partnerships with community-based organizations, they help create reliable referral pathways across healthcare, behavioral health, housing, and other essential supports.
• This is a highly field-based role, with most time spent meeting partners, engaging individuals, and expanding access to services in high-need communities.
• Street Outreach Advisors play a hands-on role in turning community connections into meaningful care access.
• Identify and prioritize community-based organizations across more than 100 categories within assigned local markets.
• Build and maintain referral-generating partnerships that support access to Enhanced Care Management, Community Supports, Behavioral Health, Street Medicine, and Case Health Worker services.
• Take ownership of an outreach territory by developing and sustaining partner relationships that produce ongoing referrals.
• Spend the majority of the workweek in the field meeting with potential partners and engaging the community through in-person outreach.
• Identify individuals who may benefit from PHG services and facilitate warm referrals or enrollments through direct engagement.
• Balance relationship building with consistent follow-through to support steady referral activity.
• Accurately document outreach activity, referrals, and partnerships in CRM tools.
• Coordinate with internal care teams to ensure referrals are tracked and closed-loop.
• Share observations and insights from the field to inform outreach strategy and improvement.
• Consistent referral generation and growth within assigned territory.
• Strong and sustained community partnerships across priority service categories.
• Accurate and timely CRM documentation and referral tracking.
• Increased community awareness and engagement with PHG services.
• Positive collaboration and feedback from internal care teams and external partners.

Street Outreach Advisor

• Our Street Outreach Advisors work directly in the community to connect individuals with the care and support services that improve health and stability.
• Spend the majority of the workweek in the field meeting with potential partners and engaging the community through in-person outreach.
• Identify individuals who may benefit from PHG services and facilitate warm referrals or enrollments through direct engagement.
• Balance relationship building with consistent follow-through to support steady referral activity.
• Accurately document outreach activity, referrals, and partnerships in CRM tools.
• Coordinate with internal care teams to ensure referrals are tracked and closed-loop.
• Share observations and insights from the field to inform outreach strategy and improvement.

• Identify and prioritize community-based organizations across more than 100 categories within assigned local markets.
• Build and maintain referral-generating partnerships that support access to Enhanced Care Management, Community Supports, Behavioral Health, Street Medicine, and Case Health Worker services.
• Take ownership of an outreach territory by developing and sustaining partner relationships that produce ongoing referrals.
• Spend the majority of the workweek in the field meeting with potential partners and engaging the community through in-person outreach.
• Identify individuals who may benefit from PHG services and facilitate warm referrals or enrollments through direct engagement.
• Balance relationship building with consistent follow-through to support steady referral activity.
• Accurately document outreach activity, referrals, and partnerships in CRM tools.
• Coordinate with internal care teams to ensure referrals are tracked and closed-loop.
• Share observations and insights from the field to inform outreach strategy and improvement.
• Consistent referral generation and growth within assigned territory.
• Strong and sustained community partnerships across priority service categories.
• Accurate and timely CRM documentation and referral tracking.
• Increased community awareness and engagement with PHG services.
• Positive collaboration and feedback from internal care teams and external partners.

General

• Manage a caseload of members with complex health and social needs
• Spend approximately 65% of your time in the field (homes, shelters, community settings)
• Conduct in-person visits, assessments, and follow-ups
• Travel locally within hiring county
• Coordinate services across healthcare, behavioral health, and community resources
• Participate in community outreach efforts including events, partnerships, and local engagement
• Provide mentorship and support to other care managers
• Document in real-time or by end of day using internal systems
• Conduct comprehensive member assessments to identify health and social needs
• Develop and manage individualized care plans
• Coordinate appointments, services, and long-term 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, food access, workforce programs, childcare, and other services
• Strengthen partnerships with community-based organizations
• Identify gaps in resources and escalate needs for program improvement
• Provide guidance, mentorship, and support to care managers within the program
• Assist with onboarding and training of new team members
• 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
• Provide feedback to leadership to improve care coordination strategies and partnerships

Manager

• Manage a caseload of members with complex health and social needs
• Spend approximately 65% of your time in the field (homes, shelters, community settings)
• Conduct in-person visits, assessments, and follow-ups
• Travel locally within Santa Clara County
• Coordinate services across healthcare, behavioral health, and community resources
• Participate in community outreach efforts including events, partnerships, and local engagement
• Provide mentorship and support to other care managers
• Document in real-time or by end of day using internal systems
• Conduct comprehensive member assessments to identify health and social needs
• Develop and manage individualized care plans
• Coordinate appointments, services, and long-term 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
• Connect members to housing, food access, workforce programs, childcare, and other services
• Provide guidance, mentorship, and support to care managers within the program
• Maintain accurate and timely documentation of all member interactions
• Ensure compliance with Medi-Cal, CalAIM, and Community Supports program requirements
• Partner with interdisciplinary teams including behavioral health, outreach, and social services
• Identify trends and gaps in services

Community Support Lead Care Manager

• Proactively conduct street-level and site-based outreach across Santa Clara County to identify, engage, and enroll eligible members into ECM and Community Supports programs.
• Build and maintain a consistent presence at community locations including shelters, transitional housing sites, hospitals, emergency departments, behavioral health clinics, food pantries, resource fairs, and encampments.
• Develop and nurture referral relationships with community-based organizations (CBOs), social workers, discharge planners, clinic staff, law enforcement outreach teams, and other partners who can refer members to PHG services.
• Represent Pacific Health Group at community events, health fairs, partner meetings, and coalition gatherings to promote services and expand referral pipelines.
• Distribute PHG outreach and marketing materials to community partners, agencies, and public-facing locations to increase awareness of available services.
• Conduct warm handoffs by introducing prospective members to Lead Care Managers and care teams, supporting a seamless transition from outreach to enrollment.
• Track outreach activities, referral sources, and conversion outcomes to support data-driven outreach strategy and continuous improvement.
• Identify gaps in community awareness of PHG services and recommend targeted outreach strategies to reach underserved populations.
• Conduct initial risk assessments in the field and office settings to understand each member’s health, behavioral health, and social needs.
• Review medical and social histories to determine eligibility for programs such as Enhanced Care Management (ECM) and Community Supports.
• Coordinate with Lead Care Managers and interdisciplinary teams to initiate and support individualized care plans.
• Ensure timely, thorough documentation in PHG systems in accordance with program and compliance requirements.
• Facilitate referrals to internal programs and external providers, ensuring timely access to care and community resources.
• Communicate with clinics, specialists, hospitals, and community-based organizations to support successful member engagement.
• Track referral outcomes and close referral loops, identifying and addressing barriers to access as needed.
• Serve as a point of contact for assigned members via phone, text, and virtual check-ins.
• Conduct follow-up outreach to support continuity of care and ongoing engagement.
• Collaborate with care managers, healthcare providers, and family members to address challenges and support member goals.
• Maintain accurate, timely, and HIPAA-compliant documentation across PHG systems for all outreach contacts, referrals, and member interactions.
• Support quality assurance efforts by auditing data for completeness and participating in continuous quality improvement initiatives.
• Collect and share member feedback to inform service enhancements and outreach workflow improvements.
• Conduct structured re-engagement efforts for inactive members via phone, text, virtual, and in-person outreach.
• Support enrollment, scheduling of assessments, and collection of required documentation.
• Support appropriate dis-enrollment processes in alignment with health plan requirements and documentation standards.

Member Engagement Specialist

• Spend approximately 65% of your time in the field (homes, community sites, events)
• Conduct outreach, assessments, and direct member engagement
• Travel within assigned county to meet members and community partners
• Support health education, care navigation, and resource coordination
• Facilitate group sessions and community-based activities
• Document services and interactions in real-time
• Conduct comprehensive assessments and develop Plans of Care
• Provide ongoing support and follow-up with members
• Assist members with care navigation, appointments, and service coordination
• Support transitions of care and continuity of services
• Deliver health education and coaching to improve self-management
• Assist members in understanding healthcare systems and accessing services
• Address barriers such as transportation, language, and access to care
• Conduct outreach to identify and engage high-risk, hard-to-reach populations
• Participate in community events, wellness fairs, and outreach initiatives
• Coordinate mobile health clinics, vaccination drives, and community activities
• Build trust within the community and support program awareness
• Facilitate group sessions and workshops on health-related topics
• Provide education on prevention, mental health, substance use, and wellness
• Support community-based learning and engagement initiatives
• Assist members with enrollment in public assistance programs
• Provide advocacy to improve access to care and services
• Support members in navigating complex healthcare and social systems
• Maintain accurate, timely documentation of all services and interactions
• Complete required reporting and billing documentation
• Collaborate with interdisciplinary teams including RNs and licensed providers
• Participate in case conferences and team meetings

Community Health Worker

• 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 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

Community Supports Lead Care Coordinator – Housing

Patient Engagement Coordinator

Data Administrator

Billing Analyst

Associate Therapist – ECM Consultant

Community Support Lead Care Coordinator

Community Support Lead – Care Coordinator

Street Outreach Advisor

Street Outreach Advisor

Street Outreach Advisor

Community Support Lead Care Coordinator

Community Support Lead Care Manager

Member Engagement Specialist

Community Health Worker

Enhanced Care Management Lead – Care Coordinator