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Care Management Community Coordinator

San Francisco Health Plan

San Francisco Health Plan

San Francisco, CA, USA
Posted on Saturday, November 18, 2023

You can make a difference on the San Francisco community in a mission-critical, member facing role and help create systemic change?

Reporting to the Clinical Supervisor of Care Management, as Care Management Community Coordinator (CMCC), you will conduct in-person bio psychosocial assessments, create person-focused holistic care plans, and function as a liaison, coordinating services among multiple providers and community agencies, splitting time at the SFHP office and in the community (at clinics and hospitals, with community-based organizations, and home visits. You will manage a diverse range of members in different programs and participate in continuous improvement projects to help build a more effective service delivery program model.

This position is based in our San Francisco office, working in a hybrid setting of office, field, and remote.


  • Conduct initial telephone or in-person assessments for members referred for care coordination services or case management, assessing medical history, psychosocial issues, resource needs, and level of function.
  • Develop and support the implementation of member-centered, individualized Care Plans.
  • Support members in identification of their own strengths and barriers to help them be successful with their Care Plans; respect members’ health choices in the care planning process
  • Track access barriers and potential quality concerns, assisting members with grievances and escalating review in coordination with program leadership
  • Partner with member in navigating the system of providers and social service agencies
  • Support members and caregivers in re-assessment and modification of Care Plan goals
  • Help connect members to cultural, community, housing and social resources
  • Complete home visits, transport and accompany members to medical appointments, and outreach to members in the community including SROs, shelters and homeless encampments.
  • With the Care Management nurse, provide support and educate individuals in chronic condition management; medication management and adherence.
  • Coordinate with the nurse to complete the member’s medical assessments and integrate the medical care plan goals.
  • Act as a liaison to hospitals, long-term care settings, outpatient providers, home health representatives, and other community agencies; provide referrals to mental health care; substance use management and treatment; transportation services and other health needs


  • One or more years of experience in community-based outreach.
  • Master’s or bachelor’s degree in a related field. (Clinical supervision for MSWs may be available for up to 1200 hours.) Associate degree, Certified Alcohol and Drug Abuse Counselor, or Community Health Worker certificates considered. Previous case management and outreach experience may be substituted for educational degrees.
  • Experience working with people with mental illness, addiction issues, or homelessness.
  • Experience working with individuals with multiple diagnoses who may have multiple barriers (e.g. mental illness, substance use, access to care, and chronic medical conditions).
  • Desire to work with homeless populations in their communities, including encampments, shelters, transitional housing, etc.
  • Ability to quickly switch focus between community-based work and office-based work. Bi-cultural, bi-lingual language skills strongly preferred. Fluent Spanish speak desired,
  • Experience with Medi-Cal or Department of Health Care Services regulations preferred
  • Proficient use of common Microsoft Word applications such as Word, Excel, Outlook and Access
  • Working knowledge and use of Trauma Informed, Harm Reduction and Person Centered language and principles.
  • Because this position requires member home visits, the incumbent must successfully complete a sex offender registry screen. May be required to pass additional background checks at agency discretion.


  • 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 is 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.