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Transitional Care Services Nurse
3 months ago
Reporting to the Nurse Manager of Transitional Care Services, the Transitional Care Services (TCS) Nurse will manage cases for members who are experiencing a transition in care from one setting or level of care to another and provide guidance to the TCS Navigator and Intake team. Your responsibilities include medical assessments, medication reconciliation, discharge risk assessments, post discharge assessments, and providing ongoing medical/nursing consultation to the TCS Navigators. You will work with the TCS Nurse Manager, participate in TCS Pod Round meetings, consult with the Medical Director, and participate in interdisciplinary meetings and trainings.
Please note that while SFHP supports a hybrid work environment, this role will be required to be onsite and in-office a minimum of 4 days per month. This position is based in our Downtown San Francisco office.
Salary: $52.56 to $64.11 per hour
WHAT YOU WILL DO:
- Coordinate post discharge care and services as indicated in the discharge documentation to ensure the member is connected to all needed services and supports.
- Perform care management within the scope of licensure for members with complex needs.
- Provide consultation to TCS Navigators on medical prioritization of a member's care plan and outreach to medical care team members (such as PCP, Specialist, Hospitalist, and ancillary providers)
- Perform responsibilities electronically and telephonically for case management or coordination of care.
- Coordinate care to support access and care continuity, especially during transitions of care. Advocate for safe discharge planning in collaboration with hospital/facility discharge planners and SFHP Utilization Management.
WHAT YOU WILL BRING:
- Active California RN license without restriction and 3 years preferred experience in case management, discharge planning, or equivalent combination of education and experience. BSN, MSN, or related degree may be considered in lieu of relevant work experience.
- Experience with public health nursing or care management with safety net populations preferred.
- Experience with NCQA, Complex Care Management requirements
- CCM certification preferred.
- Knowledge of San Francisco County community resources, Medicare and Medi-Cal.
- Medical knowledge of common medical conditions, including: Diabetes, Hypertension, End-Stage Renal Disease (ESRD), Chronic Obstructive Pulmonary Disease (COPD), Asthma, Liver Disease, Hep C and chronic wounds.
- Experience working with individuals with multiple diagnoses who may have multiple barriers (i.e., mental illness, substance use, access to care, and chronic medical conditions)
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.
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