Lead Health Care Navigator

Job Summary

The Lead Health Care Navigator (Lead HCN) will be an integral member of the Office of Population Health (OPH) TEAM Bundle Payment Team. This team will provide complex care management for the CMS TEAM Bundles patients within the UCSF Health system. This population includes patients with medical and psycho-social complexities, at risk for high utilization post-procedure. This team collaborates with many team members throughout UCSF Health along with multiple service lines to ultimately decrease the total cost of care for each patient in their respective Bundle.

As part of OPH, the Lead HCN is tasked with care coordination and transition of care work. Clinically, the Lead HCN will work to help implement and manage patient health screenings and collect medication lists for clinical staff to complete medication reconciliation. The Lead HCN will also help develop and follow care plans, provide patient education and coach on treatment recommendation to patients and their families around ongoing care management needs.

This includes high-level care coordination between primary care providers, specialists, and other healthcare team members, ensuring that patients experience seamless transitions between inpatient, specialty, primary care, and community settings. The Lead HCN also employs motivational interviewing techniques to support patients in achieving their health goals and improve self‑management of chronic conditions. In addition, this position is responsible for tracking and monitoring all TEAM Bundles patients who are admitted to any Skilled Nursing Facility (SNF), Acute Rehab (AR) or hospital for post‑acute care.

The Lead HCN will work to transition patients from the post‑acute space back to their residence, ensuring connection back to their local Primary Care provider. Programmatically, the Lead HCN plays a role in developing, evaluating, and refining the CMS TEAM Bundles program to meet UCSF Health’s population health goals in collaboration with the Lead Advance Nurse Specialist. The Lead HCN will also use data to track the post‑acute program outcomes and identify opportunities for improvement while maintaining compliance with CMS requirements.

As an extension of the clinical team, the Lead HCN is a hybrid position that will be required to rotate to all UCSF Health hospital locations, including the Office of Population Health main office in Brisbane, CA. This Lead HCN role is part of a dynamic care team within the Office of Population Health (OPH) Clinical Programs. This position will report to the Director of Clinical Programs/Vice President with direct collaboration with the Government Payor Medical Director and the Lead Advanced Nurse Specialist.

The Lead HCN will be required to be on‑site for a minimum of 4 days per week with a potential 1‑day per week remote day based on the needs of the division. This position is required to travel to all UCSF Health Hospitals (Parnassus, Mount Zion, Mission Bay, Stanyan and Hyde). The home office will be located at 8000 Marina Blvd in Brisbane and requires frequent travel to that location.

The incumbent should be able to provide a safe and private home office environment for conducting patient outreach and UCSF business.

The salary range for this position is $65,700 – $140,300 (Annual Rate). The final salary and offer components are subject to additional approvals based on UC policy. To learn more about the benefits of working at UCSF, including total compensation, please visit: (Use the "Apply for this Job" box below)..html

The Office of Population Health (OPH) leads UCSF’s development of innovative care models to improve the value and quality of care and improve health outcomes for identified populations and facilitates implementation of these care models across the health system. OPH is responsible for fulfilling UCSF Health’s accountable care contracts and fostering care partnerships across a clinical network. This department is comprised of four main teams: (1) Clinical Programs, (2) Population Health Quality and Performance Improvement, (3) Ambulatory Risk…