San Francisco Health Plan

  • Care Transitions Navigator

    Job Locations US-CA-San Francisco
    Job ID
    Health Services
    Regular Full-Time
  • Overview


    The San Francisco Health Plan (SFHP) department of Inpatient Utilization Management is working to help members transition from inpatient or skilled nursing facilities (SNF) to the next level of care to reduce unnecessary admissions and readmissions and to ensure appropriate follow through between systems of care in order to improve quality of care for our members.  The Care Transitions Navigator will work closely with members while they are hospitalized or in a SNF and post-discharge to assist them in reconnecting with their primary care physician (PCP). The Care Transitions Navigator will assist clinical staff to conduct in-person discharge planning assessments, followed by post-discharge phone calls or home visits to those members.  This position will be based at the hospitals or skilled nursing facilities with some time at the SFHP office and will function independently in the field using mobile technology for regular communication with the team and should be comfortable with online clinical documentation.



    • Assist clinical staff conduct in-person or telephonic discharge planning assessments for hospitalized members and identify their discharge needs
    • Assist clinical staff in identifying members for various programs (including care management, health homes, palliative care, etc.)
    • Serve as one of SFHP’s point of contact for members, family and hospital/SNF's for discharge planning needs
    • Contact the primary healthcare provider to facilitate notification of admission
    • Promote timely access to appropriate care as directed by clinical staff
    • Facilitate member access to appropriate medical and specialty providers upon discharge from hospital or SNF in conjunction with clinical staff
    • Promote utilization of preventative services
    • Increase the continuity of care by assisting in managing relationships with primary care providers upon discharge
    • Conduct post discharge follow-up phone calls to ensure discharge needs are met and that prescribed follow-up services are occurring
    • Support individuals in medication management, adherence, health care system navigation and other health topics as directed by or in conjunction with the clinical staff
    • Collaborate with SFHP Health Outcomes Improvement, Pharmacy, Care Coordination and Utilization Management teams in co-managing members and participating in inter-departmental workflow




    • Bachelor’s Degree is preferred
    • Associate’s degree, or Community Health Worker certificates considered
    • Experience working as a medical assistant or pharmacy technician preferred
    • Bi-cultural, bi-lingual language skills are preferred
    • A minimum of two years experience working in a clinical or community resource setting
    • Ability to navigate San Francisco independently
    • Experience working with people with mental illness, addiction issues, and/or homelessness preferred
    • Experience with Medi-Cal and/or Department of Health Care Services regulations preferred
    • Knowledge of and experience with state and federal insurance programs a plus
    • Must be PC/Mac literate and comfortable with MS Office (Word, Excel, PowerPoint, Outlook)
    • Ability to work collaboratively and independently as needed
    • Exceptional attention to detail




    Established in 1997, San Francisco Health Plan (SFHP) is a an award winning,  managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco county. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 145,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services. SFHP was designed by and for the residents it serves, and takes great pride in its ability to accommodate a diverse population that includes young adults, seniors, and people with disabilities.


    San Francisco Health Plan is an Equal Opportunity Employer (EOE M/F/D/V). 

    Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.


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