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Care Transitions Navigator

San Francisco Health Plan

San Francisco Health Plan

San Francisco, CA, USA
Posted on Tuesday, September 12, 2023

You can make a difference in the most vulnerable communities of San Francisco. The Care Transitions (CT) Navigator engages members admitted to an acute care or post-acute setting. You will focus on care coordination interventions and comprehensive member support to ensure a seamless transition across all settings and delivery systems. You will support members from discharge planning until they have been successfully connected to all needed services and supports. This position will be a hybrid of remote, field and office work.


  • Assist clinical staff to conduct in-person or telephonic discharge planning assessments for members in inpatient and post-acute settings to help identify discharge needs.
  • Assist clinical staff in identifying members for various community programs and resources.
  • Serve as one of the health plan’s points of contact for member, family and hospital/SNF for discharge planning needs
  • Coordinate care between inpatient/post-acute settings and outpatient providers.
  • 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.
  • Support 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 prescribed follow-up services are occurring.
  • Identify and coordinate with nurse, pharmacy, care management coordinators or any other interdisciplinary resources as appropriate.
  • Support individuals in medication management, adherence, health care system navigation and other health topics as directed by or in conjunction with the clinical staff.
  • Complete all required documentation in a timely fashion in accordance with regulations and program standards/workflows.


  • Associate’s degree in areas such as community health, public health, sociology or similar; or Community Health Worker certificates considered. Bachelor’s Degree preferred
  • Two years or more experience working in a clinical or community resource setting; skilled nursing facility experience preferred, care coordination skills desirable
  • Bi-cultural, bi-lingual language skills preferred, but not required; oral and written proficiency in Spanish or Cantonese is a plus
  • Experience working as a medical assistant or pharmacy technician preferred.
  • Experience working with people with mental illness, substance use, or housing instability strongly preferred
  • Experience with Medi-Cal and/or Department of Health Care Services regulations preferred
  • Experience working in a managed care environment or state and federal insurance programs a plus
  • Knowledge of San Francisco County community resources, and Medi-Cal preferred
  • Able to navigate San Francisco independently


  • Medical Plans: You’ll have a choice of medical plans, including options from Kaiser and Blue Shield of California. Employee-only coverage in the HMO plans are currently available at no cost and dependent coverage is heavily subsidized by SFHP.
  • Dental: You’ll have a choice of a basic dental plan or an enhanced dental plan which includes orthodontic coverage.
  • Vision: Employee vision care coverage is available at no cost.
  • Time Off: 23 days of Paid Time Off and 12 observed company holidays.
  • Professional development: Opportunities for tuition reimbursement, professional license/membership.


Established in 1994, San Francisco Health Plan (SFHP) is 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 170,000+ 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 proud to be an equal opportunity employer. We are committed to a work environment that supports, inspires, and respects all individuals and in which our people processes are applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristics.

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

San Francisco Health Plan is an E-Verify participating employer.

Hiring priority will be given to candidates residing in the San Francisco Bay Area and California.