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 final salary and offer components are subject to additional approvals based on UC policy. Your placement within the salary range is dependent on a number of factors including your work experience and internal equity within this position classification at UCSF. For positions that are represented by a labor union, placement within the salary range will be guided by the rules in the collective bargaining agreement. The salary range for this position is $65,700 - $140,300 (Annual Rate). To learn more about the benefits of working at UCSF, including total compensation, please visit: https://ucnet.universityofcalifornia.edu/compensation-and-benefits/index.html Department Description 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 Capture/Medicare Advantage Operations, and 4) Population Health Administration. Required Qualifications
- Advanced health Coaching and/or Care Coordination Coordinator for complex patients.
- Advanced knowledge of Patient Rights & Responsibilities, Joint Commission standards, and Centers for Medicare / Medicaid regulations. Knowledge of Medical Terminology. Advanced knowledge of data collection, compilation, and analytical techniques.
- Advanced skills to comprehend and assess patient's grievances to quickly locate appropriate resources for assistance. Advanced knowledge of the organization and how to get issues resolved.
- Advanced interpersonal and customer service skills. Ability to communicate and resolve issues effectively with a diverse population of patients, staff and physicians.
- Proficiency with Windows-based software including Microsoft word, Excel, Outlook. Knowledge of computer systems and software used in functional area.
- Excellent analytical and problem-solving skills. Ability to develop solutions and recommend changes and follow through with implementation.
- Advanced written and verbal communication skills.
- BA/BS degree and a minimum of 5+ years previous experience in a healthcare related field OR an equivalent combination of education and experience (e.g. EMT, health educator, community health worker, social worker, health plan, medical corps and clinical office. staff.)
Preferred Qualifications
- Advanced analytical and problem-solving skills. Ability to develop solutions and recommend changes and follow through with implementation.
- Related Care Management work with surgical services specifically around Cardiology, Neurology, Orthopedics or major bowel procedures
- Master's degree
- Health Coaching (Certificate)
- Case Management (Certificate)
About UCSF At UCSF Health, our mission of innovative patient care, advanced technology and pioneering research is redefining what's possible for the patients we serve - a promise we share with the professionals who make up our team.
Consistently ranked among the top 10 hospitals nationwide by U.S. News & World Report - UCSF Health is committed to providing the most rewarding work experience while delivering the best care available anywhere. In an environment that allows for continuous learning and opportunities for professional growth, UCSF Health offers the ideal atmosphere in which to best use your skills and talents. Pride Values UCSF is a diverse community made of people with many skills and talents. We seek candidates whose work experience or community service has prepared them to contribute to our commitment to professionalism, respect, integrity, diversity and excellence - also known as our PRIDE values.
In addition to our PRIDE values, UCSF is committed to equity - both in how we deliver care as well as our workforce. We are committed to building a broadly diverse community, nurturing a culture that is welcoming and supportive, and engaging diverse ideas for the provision of culturally competent education, discovery, and patient care. Additional information about UCSF is available at diversity.ucsf.edu
Join us to find a rewarding career contributing to improving healthcare worldwide. Equal Employment Opportunity The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected status under state or federal law. Job Code and Payroll Title 005205 PAT NAVGTR NON-CLIN 4 CX Job Category Administrative Support Bargaining Unit Teamsters Local 2010 - Clerical and Allied Services Unit (CX) Location San Francisco, CA Additional Shift Details Monday - Friday |
University of California - San Francisco Campus and Health
Dec 13, 2025