Care Management Nurse

Reporting to the Clinical Supervisor, Care Management, the Care Management Nurse provides clinical assessment, nursing interventions, and coordinated care planning for SFHP members with complex and chronic health needs across multiple programs. Working in close partnership with Care Management Community Coordinators (CMCCs), the nurse evaluates medical risks, conducts nursing assessments, delivers chronic-condition evaluation, reconciles medications, and supports members in navigating care across multiple settings.

Salary: $60.00 to $65.00 per hour. The position is located in Downtown San Francisco with travel throughout the city for home visits, engage clinics, and community-based casework. It is a hybrid role requiring onsite presence at least four days per month.

• Conduct comprehensive medical assessments to identify risks, chronic‑condition needs, medication issues, and barriers to care.
• Review clinical information across multiple Electronic Medical Records (EMRs) and summarize main medical elements in the care‑management system.
• Provide disease‑specific education, medication reconciliation, and nursing guidance to strengthen member understanding.
• Develop and update member‑centered nursing care plans aligned with medical priorities and member goals.
• Co‑manage a substantial caseload, up to 150 cases, offering CMCC partners nursing guidance on triage, medical prioritization, and clinically appropriate follow‑up.
• Maintain case documentation, status updates, and care‑plan revisions following program workflows, regulatory standards, and internal timelines.
• Support CMCCs in addressing complex medical questions, navigating provider systems, and escalating clinical issues.
• Collaborate on care‑plan development and ensure nursing interventions align with psychosocial and medical needs.
• Ensure regular member engagement through outreach, telephonic contact, EMR review, and collaboration with CMCCs to support care‑plan progress.
• Communicate with PCPs, specialists, hospitals, inpatient/facility teams, and ancillary providers to support coordinated, appropriate care.
• Facilitate transitions of care through discharge coordination, post‑discharge education, medication review, and assistance with follow‑up appointments.
• Coordinate with Utilization Management, Pharmacy, Behavioral Health, and other teams on medical and pharmacy needs related to member care plans.
• Participate in interdisciplinary case reviews, RN group guidance, and consultations with Medical Directors on complex or nuanced cases.
• Be a nursing resource to internal and external partners to ensure understanding of medical, behavioral, and social services.
• Monitor admissions and discharges and engage promptly in transition‑focused care planning.
• Advocate for safe and appropriate discharge planning in collaboration with facility staff, hospital teams, and SFHP Utilization Management.
• Complete post‑discharge outreach, medication reconciliation, chronic‑condition teaching, and follow‑up coordination with established timelines.
• Accompany members to follow‑up appointments when clinically appropriate to support continuity of care and adherence to treatment recommendations.
• As indicated, perform Initial Medical Assessments for inpatient members newly referred into Care Management.
• Conduct home visits and other field‑based assessments to evaluate environmental, social, and clinical factors that influence health outcomes.
• Collaborate with community partners to support access, service coordination, and integrated care.
• Apply trauma‑informed, harm reduction, and person‑centered principles across all interactions with members and caregivers.
• Identify workflow issues, care‑coordination challenges, and barriers to timely care, and raise them for resolution or contribute to improvement efforts.
• Participate in departmental projects related to quality, compliance, and clinical operations.
• Model high‑quality documentation and communication practices to support team effectiveness and audit readiness.

• Active California RN or LVN license without restriction and in good standing, required.
• At least 3 years of nursing experience in care management, case…