UCSF Health
Lead Health Care Navigator
Job Summary:
The Lead Health Care Navigator (Lead HCN) is an integral member of the Office of Population Health (OPH) TEAM Bundle Payment Team. The role provides complex care management for CMS TEAM Bundles patients within the UCSF Health system, focusing on individuals with medical and psycho-social complexities who are at risk for high utilization post-procedure. The Lead HCN coordinates care, transitions, and support across primary care, specialty, inpatient, acute rehab, and community settings to reduce total patient cost and improve outcomes.
Responsibilities:
Implement and manage patient health screenings, medication list collection, and medication reconciliation with clinical staff.
Develop and follow patient care plans, provide education, and coach on treatment recommendations.
Coordinate high-level care across providers, ensuring seamless transitions between inpatient, specialty, primary, and community care.
Use motivational interviewing techniques to support patients in health goal attainment and chronic condition self‑management.
Track and monitor all TEAM Bundles patients admitted to SNF, AR, or hospital for post‑acute care and transition them back to local Primary Care.
Assist in evaluating and refining the CMS TEAM Bundles program, collaborating with the Lead Advance Nurse Specialist.
Use data to track program outcomes and identify improvement opportunities while maintaining CMS compliance.
Rotate to all UCSF Health hospital locations and the OPH main office; maintain on‑site presence at least 4 days per week with optional remote day.
Provide a private home office environment for patient outreach as required.
Required Qualifications:
Advanced health coaching or care coordination experience with complex patients.
Comprehensive knowledge of Patient Rights & Responsibilities, Joint Commission standards, CMS/Medicare regulations, and medical terminology.
Strong analytical, problem‑solving, and data‑collection skills.
Advanced interpersonal and customer‑service skills, effective communication with diverse populations.
Proficiency with Windows‑based software (Word, Excel, Outlook). Familiarity with related computer systems.
BS/BA degree and 5+ years of healthcare‑related experience (e.g., EMT, health educator, social worker, case manager, medical office staff).
Preferred Qualifications:
Experience in care management for surgical services (Cardiology, Neurology, Orthopedics, major bowel procedures).
Master’s degree or certifications in Health Coaching or Case Management.
Advanced analytical and problem‑solving skills with implementation experience.
Salary Range:
$65,700 – $140,300 (Annual Rate). Final salary and offer components are subject to additional approvals and UC policy. Benefits information can be found at
UCSF Compensation & Benefits .
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.
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The Lead Health Care Navigator (Lead HCN) is an integral member of the Office of Population Health (OPH) TEAM Bundle Payment Team. The role provides complex care management for CMS TEAM Bundles patients within the UCSF Health system, focusing on individuals with medical and psycho-social complexities who are at risk for high utilization post-procedure. The Lead HCN coordinates care, transitions, and support across primary care, specialty, inpatient, acute rehab, and community settings to reduce total patient cost and improve outcomes.
Responsibilities:
Implement and manage patient health screenings, medication list collection, and medication reconciliation with clinical staff.
Develop and follow patient care plans, provide education, and coach on treatment recommendations.
Coordinate high-level care across providers, ensuring seamless transitions between inpatient, specialty, primary, and community care.
Use motivational interviewing techniques to support patients in health goal attainment and chronic condition self‑management.
Track and monitor all TEAM Bundles patients admitted to SNF, AR, or hospital for post‑acute care and transition them back to local Primary Care.
Assist in evaluating and refining the CMS TEAM Bundles program, collaborating with the Lead Advance Nurse Specialist.
Use data to track program outcomes and identify improvement opportunities while maintaining CMS compliance.
Rotate to all UCSF Health hospital locations and the OPH main office; maintain on‑site presence at least 4 days per week with optional remote day.
Provide a private home office environment for patient outreach as required.
Required Qualifications:
Advanced health coaching or care coordination experience with complex patients.
Comprehensive knowledge of Patient Rights & Responsibilities, Joint Commission standards, CMS/Medicare regulations, and medical terminology.
Strong analytical, problem‑solving, and data‑collection skills.
Advanced interpersonal and customer‑service skills, effective communication with diverse populations.
Proficiency with Windows‑based software (Word, Excel, Outlook). Familiarity with related computer systems.
BS/BA degree and 5+ years of healthcare‑related experience (e.g., EMT, health educator, social worker, case manager, medical office staff).
Preferred Qualifications:
Experience in care management for surgical services (Cardiology, Neurology, Orthopedics, major bowel procedures).
Master’s degree or certifications in Health Coaching or Case Management.
Advanced analytical and problem‑solving skills with implementation experience.
Salary Range:
$65,700 – $140,300 (Annual Rate). Final salary and offer components are subject to additional approvals and UC policy. Benefits information can be found at
UCSF Compensation & Benefits .
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.
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