Care Transitions Program Coordinator

San Francisco Community Health Center•San Francisco, CA

20h•Onsite

About The Position

The Care Transitions Program Coordinator will lead the implementation of Enhanced Care Management (ECM) services in partnership with hospital systems, supporting high-need patients during and after hospital encounters. This role is responsible for identifying eligible patients, facilitating real-time enrollment, and ensuring seamless transitions from hospital to community-based care. Working closely with hospital care teams, the Program Coordinator will conduct bedside outreach, coordinate discharge planning, and connect patients to ongoing services through CalAIM Enhanced Care Management. The role also includes responsibility for program tracking, reporting, and continuous improvement to reduce avoidable utilization and improve patient outcomes.

Requirements

Bachelor’s degree in public health, social work, healthcare administration, or related field (or equivalent experience).
2 years of experience in care coordination, case management, or healthcare program implementation.
Experience and comfort working with sexual and gender minorities, refugees, immigrants, homeless, and those with substance use and/or mental health issues.
Strong interpersonal skills and ability to engage diverse patient populations.
Experience working in interdisciplinary teams and with hospital settings, especially Emergency Department workflows.
Familiarity with Medi-Cal and care management models, including CalAIM Enhanced Care Management.
Experience with ECM or similar population health programs.
Background in working with high-utilizing or medically complex populations.
Must be able to handle multiple tasks and can work professionally and ethically within multi-racial and multicultural settings.
Experience with data tracking, reporting, and care management platforms (e.g., PointClickCare).
Knowledge of legal mandates and ethical issues related to client privacy and confidentiality.
Patient-centered engagement and communication.
Problem-solving in fast-paced clinical environments.
Strong knowledge of Microsoft Office, documentation in an electronic health record, and data entry and management.

Nice To Haves

Bilingual or multilingual skills

Responsibilities

Conduct regular rounding in the Emergency Department and as needed, inpatient units to identify and engage eligible patients.
Screen patients for ECM eligibility and priority population criteria.
Provide bedside outreach, education, and enrollment into ECM services.
Collaborate with hospital care teams to support safe and timely discharge planning.
Facilitate warm handoffs to community-based care teams following discharge.
Verify eligibility for ECM services in real time through coordination with Managed Care Plans.
Complete and submit enrollment documentation and ensure timely processing.
Connect patients to appropriate medical, behavioral health, and social services.
Support continuity of care by coordinating with internal and external care teams.
Build and maintain strong working relationships with hospital staff, including ED teams, case managers, and social workers.
Conduct educational sessions and provide ongoing training to hospital staff on ECM program eligibility, benefits, and workflows.
Serve as a primary point of contact between the organization and hospital partners.
Support implementation of workflows outlined in partnership agreements (MOUs).
Maintain accurate and up-to-date records of patient outreach, screening, enrollment, and engagement activities using PointClickCare and other systems.
Track key program metrics, including number of patients screened, enrolled, and successfully linked to services.
Prepare and deliver regular reports to internal leadership and hospital partners.
Monitor trends in utilization (e.g., ED visits, readmissions) and identify opportunities for improvement.
Participate in regular program review meetings with internal and external stakeholders.
Identify operational challenges and recommend workflow improvements.
Contribute to the ongoing development and scaling of ECM services.
Assist with other duties as needed.