PACE Care & Resource Navigator

Family Health Centers of San Diego; Oceanside (CA); On-site; USD 33,000 - 41,000; Full time

Job summary

Family Health Centers of San Diego is seeking a social services coordinator to support participants and caregivers in navigating community resources and care coordination under Social Worker supervision. The role emphasizes outreach, documentation, and patient-centered care.

Responsibilities include assisting with Medi-Cal/CalFresh access, coordinating referrals, conducting home visits, and maintaining compliant records across sites. Travel between San Diego County locations is required.

Qualifications

• Bachelor’s degree in social work or related field preferred.
• Current American Heart Association healthcare provider CPR (BLS), or Advanced Cardiac Life Support, Advanced Trauma Life Support, or Advanced Resuscitation Training required.
• Traveling between sites and other locations is required as an essential function of the job. Must have a car, a valid California driver’s license, and proof of minimum levels of car insurance as required under California law, although limits of $100,000 are recommended.

Responsibilities

• Assist participants with applications and access to community resources and social service programs, including Medi-Cal, CalFresh, housing resources, transportation services, financial assistance programs, and other supportive services.
• Assist Social Workers with case management activities and follow-up for participants and caregivers.
• Serve as a liaison between participants, families, caregivers, community agencies, hospitals, skilled nursing facilities, assisted living facilities, and the interdisciplinary team.
• Support transitions of care, including hospital admissions, hospital discharges, skilled nursing facility admissions and discharges, and community placements.
• Assist with scheduling and coordinating family meetings, care conferences, and participant-related meetings.
• Provide telephone support and participant follow-up as directed by the Social Worker.
• Conduct home visits and community visits as assigned and under the direction of the Social Worker.
• Assist participants with completion of forms, applications, benefit renewals, and document management activities.
• Coordinate referrals to community agencies and supportive services.
• Maintain current case management records and documentation in accordance with organizational standards and regulatory requirements.
• Assist with collection and organization of participant information for interdisciplinary care planning activities.
• Support participant enrollment, disenrollment, transfers, and continuity of care processes.
• Communicate participant concerns, psychosocial needs, and significant changes to the Social Worker and interdisciplinary team in a timely manner.
• Participate in interdisciplinary team meetings, care planning discussions, and departmental meetings as assigned.
• Assist with participant engagement activities, support groups, educational programs, recreational activities, and community outings.
• Maintain confidentiality and comply with HIPAA, CMS, DHCS, and organizational requirements.

Skills

Case management

Care coordination

Social services

Community outreach

Behavioral health

Senior services

Disabilities

Vulnerable populations

Bilingual English/Spanish

Education

Bachelor’s degree in social work or related field preferred

Job description

Family Health Centers of San Diego is seeking a social services coordinator to support participants and caregivers in navigating community resources and care coordination under Social Worker supervision. The role emphasizes outreach, documentation, and patient-centered care.

Responsibilities include assisting with Medi-Cal/CalFresh access, coordinating referrals, conducting home visits, and maintaining compliant records across sites. Travel between San Diego County locations is required.