Jobs Home > Case Management > CA - California (All) > Health Plan of San Mateo > CARE TRANSITIONS NURSE CASE MANAGER


Health Plan of San Mateo Type Full time Posted 7/23/2014
Salary - n/a - Starts - n/a -
CA - California (All) - San Mateo Referral - n/a -    



The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time Care Transitions Nurse Case Manager to function as a facilitator of interdisciplinary collaboration and care continuity from hospital to home, coaching the member and caregiver to play an active and informed role in care plan execution. This position will report to the Senior Health Services Clinical Manager.

Primary duties:

  • Perform comprehensive assessments and care planning.
  • Perform onsite member identification participation into Care Transition program.
  • Meet with member and/or caregiver to introduce program, discuss scope of coach responsibility, obtain member/caregiver participation, and establish home visit plan. 
  • Contact healthcare provider to establish medical record, plan treatment, and develop documentation of care plan.
  • Contact HPSM identified high risk members to establish plan of care with understanding of goals as developed with PCP.
  • Communicate with members and/or family/responsible party to initiate and develop individualized care plans via telephone.
  • Provide clinical and liaison services, follow member through continuum of care (hospitalization/SNF) and through to discharge home; perform follow up telephone calls.
  • Assist members with appointments for specialists, educational classes, and transportation.
  • Assist with medication reconciliation in collaboration with attending physician and/or Primary Care Physician.
  • Apply essential four pillars of the Care Transition conceptual model: medication self management, use of a patient-centered record, primary care and specialist follow up, and knowledge of red flags.
  • Assess for/make appropriate referrals to Care Management for necessary involvement i.e. Disease Management, Health Education, Quality Management, Provider Services, and San Mateo County Behavioral Health and Recovery Services when medical/behavioral health condition or needs are appropriate.


License: Valid California license as a Registered Nurse. Valid license as a Public Health Nurse.

Education and Experience equivalent to: Bachelor’s degree in nursing or a related health or social services field. Two years clinical nursing experience. Work in the geriatric nursing field.

Knowledge of: Case management principles and practices. Medicare and Medi-Cal programs/benefits. The complexities of working with the elderly and disabled populations.  Community resources.

Ability to: Work efficiently with people in varying positions. Gain consensus on resolution of problems. Provide excellent customer service. Effectively communicate both verbally and in writing. Utilize personal computers and Microsoft Office products (Word, Excel, Access and Outlook). Work and problem solve independently in most instances: require limited supervision. 

Other: The incumbent must have own vehicle and valid driver’s license with proof of insurance in conformity with state law minimums. Bilingual skills in Tagalog are required.

BENEFITS INFORMATION: Excellent benefits package offered including HPSM paid premiums for employee’s coverage in the medical HMO plan and majority of PPO medical cost.  Employee pays a small portion of the dependent premiums for medical and dental benefits.  Additional HPSM benefits include fully paid vision, life, AD&D, STD, and LTD insurance; 457 Plan in lieu of social security (7.5% of salary/HPSM paid); retirement plan (10% of salary for compensation/HPSM paid); holiday and vacation pay; tuition reimbursement plan; and more.

APPLICATION PROCESS: To apply, submit a resume and cover letter with salary expectations to: Health Plan of San Mateo, Human Resources Department, 701 Gateway Blvd., Suite 400, South San Francisco, CA 94080. Or via Email: careers@hpsm.org. Or via Fax: (650) 616-8039  File by: Continuous until filled.  EOE