Reporting to Clinical Supervisor, Care Management, the Care Management Community Coordinator (CMCC) conducts biopsychosocial assessments. The CMCC develops person-centered plans and serves as a liaison across multiple clinical providers, community agencies, and social-service partners. Although primarily based in the SFHP office, the role includes limited community-based fieldwork, including clinic and hospital visits, work with community-based organizations, and occasional home visits.

The CMCC manages a diverse caseload across several care-management programs, requiring strong attention to detail and adherence to program workflows and documentation standards. The company expects the role to operate independently, using mobile technology and online clinical documentation systems to support casework. CMCCs also contribute to continuous improvement efforts that enhance the efficiency, effectiveness, and equity of SFHP's care-delivery model.

Please note that while SFHP supports a hybrid work environment, SFHP requires you to work onsite and in-office a minimum of 4 days per month. This is a hybrid position, based in our Downtown San Francisco office.

Salary: $36.06 - $40.86 per hour

WHAT YOU WILL DO:

• Conduct initial assessments for members referred for care coordination or case management, including medical history, psychosocial factors, functional status, and resource needs.
• Develop individualized, member-centered care plans and support implementation in partnership with the interdisciplinary care team.
• Support members in identifying strengths and barriers to achieving their goals, and incorporate member preferences and health choices into care planning.
• Track access barriers and potential quality concerns; assist members with grievances and escalate issues.
• Partner with members to navigate provider networks, social-service systems, and community resources.
• Assist members and caregivers in updating care-plan goals as needs evolve.
• Connect members to community, housing, cultural, transportation, and social-support resources.
• Conduct home visits as needed; transport or accompany members to medical appointments when appropriate.
• Participate in the interdisciplinary Care Management department, offering insights to improve service delivery and support member wellness.
• Participate in trainings, team meetings, and case conferences; ensure the full care team is engaged in coordinated care.
• In collaboration with the CM Nurse, provide member education on chronic disease management, medication adherence, and care-plan integration.
• Facilitate referrals and support appropriate connections to mental-health care, substance-use treatment, transportation, and other services.
• Guide members through housing-stability activities, including applications and advocacy for permanent supportive housing.
• Coordinate care-management activities with nurses, pharmacists, and other clinical partners, requesting consultation.
• Complete accurate documentation following regulatory, program, and workflow requirements.
• Maintain privacy according to applicable regulations and SFHP standards.
• Collaborate with other SFHP departments on shared cases and participate in projects.
• Be a liaison to hospitals, long-term care facilities, outpatient providers, home health agencies, and other community partners.
• Participate in regular supervision, communicate concerns, and represent the program to internal and external stakeholders.

WHAT YOU WILL BRING:

• Minimum one year of community-based outreach experience.
• Bilingual language skills (Spanish, Cantonese, Vietnamese, or Tagalog).
• Master's or Bachelor's degree in a related field preferred; clinical supervision for MSWs may be available for up to 1,200 hours.
• Associate's degree, Certified Alcohol & Drug Abuse Counselor, or Community Health Worker certifications considered.
• Previous case-management and outreach experience may substitute for educational degree requirements.
• Experience working with individuals affected by mental illness, substance use, or homelessness.
• Discuss behavioral-health conditions in collaboration with clinical providers.
• Working knowledge of Trauma-Informed Care, Harm Reduction, and Person-Centered practices.
• Knowledge of San Francisco community resources, Medicare, Medi-Cal, and support systems for individuals with multiple diagnoses and barriers to care.
• Comfort working in community settings, including encampments, shelters, and transitional housing environments.
• Basic medical knowledge, including recognition of safety concerns, trauma symptoms, and chronic-disease indicators.
• Experience with Medi-Cal or DHCS regulations preferred.
• Must pass a sex-offender registry screen and may be subject to additional background checks due to home-visit requirements.

WHAT WE OFFER:

• Health Benefits
  • Medical: You'll have a choice of medical plans, including options from Kaiser and Blue Shield of California, 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.

ABOUT SFHP:

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.

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.

#LI-Hybrid

(Hybrid remote/in-office)