Care Management Community Coordinator

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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

• 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 elevate 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.

• 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…