Pacific Health Group

General

• 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

Enhanced Care Management Lead – Care Coordinator

• 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

• This is a high-impact, field-based role supporting members in the community.
• 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
• Identify opportunities to expand community presence and improve member access to services
• 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

Enhanced Care Management Lead, Care Coordinator

• 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
• Complete timely and accurate documentation
• Maintain compliance with Medi-Cal, CalAIM, and ECM program requirements

Enhanced Care Management Lead Care Coordinator

• 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
• 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

Lead Care Coordinator

• 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
• 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

• Spend approximately 50% of your time in the field and 50% managing pipelines and coordination
• Travel across assigned regions to attend hiring events, outreach efforts, and community partnerships
• Build and maintain active candidate pipelines for priority roles
• Drive candidate engagement, assessments, and follow-up throughout the hiring process
• Manage multiple open roles simultaneously with speed, organization, and accuracy
• Utilize recruiting platforms and tools to track candidate progress in real-time
• This role requires strong time management, independence, and comfort working in fast-paced, people-facing environments

Talent Engagement Specialist

• 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
• 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

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
• 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

• 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

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
• 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

Community Support Lead Care 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
• 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

Program Manager

• Hold ultimate accountability for the success of the CFS program and the achievement of Behavioral Health Service Act (BHSA) goals.
• Supervise, train, and support a team of two field-based Family Support Specialists.
• Collaborate closely with Sonoma County DHS-BHD, Full Service Partnership (FSP) teams, and PHG’s administrative staff.
• Monitor data, evaluate key performance indicators (KPIs), and submit regular reporting to County partners.
• Provide daily supervision and guidance to Family Support Specialists, ensuring they deliver culturally responsive, trauma-informed, and evidence-based services.
• Prepare, maintain, and ensure staff adherence to the CFS Program Operating Manual, including comprehensive staff training guidelines.
• Manage the successful implementation of educational workshops and weekly drop-in Resource Clinics.
• Lead meetings with County personnel and FSP teams to finalize, implement, and maintain streamlined referral and coordination protocols.
• Act as the primary liaison alongside the Quality Assurance (QA) team to address systemic barriers and coordinate with related County programs.
• Ensure structured policies, procedures, and strong documentation standards are maintained to ensure program accountability.
• Analyze program metrics quarterly with the QA team to address service disparities, develop quality improvement strategies, and maximize community impact.
• Track service utilization, demographic profiles, and efficiency using the designated Electronic Health Record (EHR) system.
• Submit detailed Quarterly Reports to the County, outlining initial KPI reviews and action plans for ongoing improvement.
• Ensure the program is effectively meeting BHSA goals, including reducing homelessness, unemployment, and psychiatric inpatient utilization.
• Support the integration of ECM and CS with Specialty Mental Health Services (SMHS) to create a seamless system of care.
• Generate ECM and CS referrals through community partnerships, educational workshops, and family resource clinics.
• Collaborate with PHG’s ECM and CS leadership, data and compliance teams to track outcomes and maintain regulatory standards.

Member Engagement Specialist

Community Health Worker

Enhanced Care Management Lead – Care Coordinator

Enhanced Care Management Lead – Care Coordinator

Enhanced Care Management Lead, Care Coordinator

Enhanced Care Management Lead Care Coordinator

Lead Care Coordinator

Enhanced Care Management Lead – Care Coordinator

Talent Engagement Specialist

Community Support Lead Care Coordinator

Community Support Lead Care Coordinator

Community Support Lead Care Coordinator

Community Support Lead Care Manager

Community Support Lead Care Manager

Program Manager – CFS Program