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Care Transitions Navigator

San Francisco Health Plan

San Francisco Health Plan

San Francisco, CA, USA
Posted on Wednesday, February 7, 2024

You can make a difference in the most vulnerable communities of San Francisco. The Care Transitions (CT) Navigator whose primary functions are member engagement while the member is admitted to an acute care or post-acute setting, providing focused care coordination interventions and comprehensive member support to ensure a seamless transition across all settings and delivery systems. You will coordinate member’s discharge planning with the facility until they have been successfully connected to all needed services and supports. You will work in close collaboration with providers and other community care workers to facilitate primary care and community programs linkage to ensure safe discharges and reduce unnecessary readmissions.

This position will be a hybrid of remote and office work at this time with the potential for field work in the future.


  • Work closely with discharge facility staff to coordinate discharge planning and complete assessments for members in inpatient and post-acute settings to help identify discharge needs.
  • Identify members for various community programs and resources.
  • Serve as one of the health plan’s points of contact for members, 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.
  • Promote utilization of preventative services
  • Support continuity of care by assisting in managing relationships with primary care providers upon discharge
  • Conducts post discharge follow-up phone calls to ensure discharge needs are met and 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.
  • Complete all required documentation in a timely fashion in accordance with regulations and program standards/ workflows.
  • Maintain privacy and confidentiality practices in accordance with regulations/program standards.
  • Internal collaboration with SFHP’s various teams, programs, and stakeholders in co-managing members and participating in interdepartmental workflows.
  • Participate in scheduled staff meetings and trainings.
  • Appropriately escalate concerns to the member’s healthcare team and management as necessary, seeking support and guidance proactively.
  • Represents the program to internal and external stakeholders.
  • Conduct data entry and maintain databases as needed for reporting requirements.
  • Foster an environment that solicits and enlists diverse and inclusive perspectives and approaches to better serve our staff, our members, and our providers.


  • Associate 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


  • A competitive and robust compensation package, including:
  • Health benefits
    • Medical: 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 through Vision Service Plan (VSP).
  • Retirement – Employer-matched CalPERS Pension and 401(a) plans, 457 Plan.
  • Time off – 23 days of Paid Time Off (PTO) and 13 paid holidays.
  • Professional development: Opportunities for tuition reimbursement, professional license/membership.
  • An opportunity to work in a vibrant atmosphere with the most amazingly talented people who are shaping the future of healthcare!
  • The chance to make a difference in the lives of many San Francisco residents!


Established in 1997, 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 175,000+ 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.