Pacific Health Group

Care Coordinator

• Manage a caseload of approximately 60–70 members
• 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, including hospital discharges and referrals
• 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 through community 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
• Identify gaps in resources and escalate when needed
• Complete timely and accurate documentation
• Maintain compliance with Medi-Cal, CalAIM, and ECM program requirements
• Provide administrative support across Pacific Health Group
• Support coordination between departments and business units and assist department managers with ongoing tasks and cross-functional priorities
• Represent Pacific Health Group and its affiliates professionally with staff, visitors, vendors, partners, and community stakeholders
• Perform accurate data entry and maintain company databases, tracking systems, and internal platforms
• Organize and manage electronic files securely and according to company standards
• Prepare reports, spreadsheets, and presentations
• Partner with internal teams, providers, and community stakeholders
• Participate in case conferences and care coordination meetings

Enhanced Care Management Lead Care Coordinator

IT Support

• Own all technology systems, data security, and regulatory compliance end to end
• Architect and maintain an organization-wide Information Security Program
• Define and enforce security controls across applications, infrastructure, devices, and users
• Establish policies for data classification, encryption, access control, logging, monitoring, and retention
• Ensure least-privilege access and zero-trust principles across systems
• Serve as the internal authority for HIPAA Security Rule and Privacy Rule compliance
• Safeguard the creation, storage, transmission, and disposal of PHI
• Maintain compliance documentation, risk assessments, and audit evidence
• Lead HIPAA risk analyses and remediation plans
• Oversee Business Associate Agreements from a security and IT standpoint
• Coordinate and support audits, assessments, and investigations
• Oversee cloud platforms, networks, connectivity, endpoints, SaaS applications, and internal tools
• Implement backup, disaster recovery, business continuity, redundancy, and failover strategies
• Approve and govern technology deployments and architectural changes
• Establish incident response plans and lead responses to security incidents and data exposure
• Conduct root cause analysis and implement corrective actions
• Maintain logs, alerts, and monitoring systems
• Govern sensitive data, PHI, confidential business information, data access, sharing, and retention
• Evaluate and monitor third-party vendor security and compliance
• Develop and enforce IT and security policies across all staff
• Deliver security awareness training
• Define the long-term IT and security roadmap
• Report security risks, compliance status, incidents, trends, and improvement initiatives to executive leadership
• Advise leadership on technology risk, investments, and trade-offs

IT Manager

Nurse

• Serve as the primary clinical resource for Enhanced Care Management (ECM) care teams
• Provide clinical consultation and guidance to Lead Care Managers, Community Health Workers, Licensed Vocational Nurses, and interdisciplinary team members
• Review complex member cases and recommend care plans, interventions, risk mitigation, and treatment coordination
• Participate in interdisciplinary case reviews, case conferences, and care team meetings
• Support implementation and ongoing success of CalAIM Enhanced Care Management services
• Coordinate care with health plans, providers, hospitals, behavioral health agencies, and community-based organizations
• Support care transitions after hospitalizations, emergency department visits, skilled nursing facility discharges, and other significant healthcare events
• Conduct field visits and shadow care team members to assess service delivery, member engagement, documentation, safety, and program standards
• Provide real-time coaching, mentorship, clinical consultation, and direct clinical supervision to LVNs
• Monitor LVN clinical activities, documentation, assessments, care coordination, and member interactions
• Conduct quality assurance reviews and monitor compliance with Medi-Cal ECM requirements
• Facilitate communication among interdisciplinary team members and address gaps in care and service coordination
• Maintain accurate, timely, compliant documentation and support audit readiness
• Develop and deliver clinical training on chronic disease management, medication safety, behavioral health, symptom recognition, healthcare navigation, and clinical best practices
• Analyze clinical and programmatic outcomes and participate in quality improvement initiatives
• Monitor member outcomes, utilization trends, care coordination effectiveness, quality metrics, and compliance indicators
• Travel throughout the hiring county for field visits, supervision, coaching, member care coordination, community meetings, and quality assurance reviews

Part-Time Registered Nurse – Clinical Case Consultant

• Provide day-to-day support and guidance to fellow Lead Care Managers
• Serve as a resource for staff questions, workflows, and ECM best practices
• Monitor team productivity, documentation completion, and operational consistency
• Identify and escalate concerns, risks, workflow gaps, and trends to management
• Support coverage needs, including member follow-up when assigned LCMs are unavailable
• Collaborate with leadership to maintain accountability, performance standards, and quality of care
• Support onboarding and ongoing development of LCMs
• Provide shadowing, coaching, guidance, and operational support to staff
• Demonstrate best practices for member engagement, documentation, outreach, and care coordination
• Provide direct member support and care coordination based on operational and coverage needs
• Coordinate medical, behavioral health, and community-based services
• Assist with transitions of care, hospital discharges, referrals, and follow-up coordination
• Build supportive relationships with members through person-centered engagement
• Participate in community-based outreach across multiple counties
• Assist with identifying, engaging, and enrolling eligible members into ECM, Community Supports, and Behavioral Health programs
• Support community partnership development and outreach efforts
• Maintain timely, accurate, and compliant documentation under Medi-Cal, CalAIM, and ECM requirements
• Support quality improvement and internal auditing processes
• Ensure care coordination activities are documented in company systems

Lead Care Coordinator

• Manage a caseload of approximately 60–70 members
• Conduct 3–5 in-person visits per day in homes, shelters, and community settings
• Spend 60–70% of 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, including hospital discharges and referrals
• 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 at 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
• Identify resource gaps 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

• Support members participating in CalAIM Community Supports Housing programs, including Housing Transition Navigation Services, Housing Tenancy & Sustaining Services, and Housing Deposit assistance
• Conduct outreach, intake assessments, comprehensive member assessments, in-person visits, follow-ups, and housing care management
• Build partnerships with housing providers, shelters, landlords, healthcare providers, and community organizations
• Coordinate housing applications, Housing Deposit Services packages, landlord allocations, appointments, services, and long-term housing support
• Develop and manage individualized housing care plans
• Monitor housing stability and proactively address barriers to housing and health outcomes
• Build trusting relationships with members and families; provide phone, video, and in-person support
• Advocate for timely care, services, and equitable access to resources
• Represent Pacific Health Group at outreach events and local initiatives
• Navigate community resources, identify service gaps, and escalate needs for program improvement
• Maintain accurate, timely, high-fidelity documentation and comply with Medi-Cal, CalAIM, and Community Supports requirements
• Track member progress, outcomes, and service delivery
• Collaborate with behavioral health, outreach, social services, healthcare providers, payers, and interdisciplinary teams
• Provide peer cross-coverage and assist with new Lead Care Manager shadowing sessions
• Participate in leadership coaching and continuously improve workflows
• Spend approximately 65% of time in the field and travel locally within the county and surrounding counties

Enhanced Care Management Lead Care Coordinator

IT Manager

Part-Time Registered Nurse – Clinical Case Consultant

Lead Care Coordinator

Enhanced Care Management Lead – Care Coordinator

Community Supports Lead Care Coordinator – Housing