• General
  • Anywhere


FLSA Status: Non-Exempt

REPORTS TO: Director of Nursing Services

DEPARTMENT: Family Medicine

WORKSITE: Ravenswood Family Health Network, All Sites


The mission of Ravenswood Family Health Network (RFHN) is to improve the health of the community by providing culturally sensitive, integrated primary and preventative health care to all, regardless of ability to pay or immigration status, and collaborating with community partners to address the social determinants of health.


Under the administrative direction of the Director of Nursing Services and the clinical direction of the Chief Medical Officer, the RN Care Coordinator (RCC) works within the interdisciplinary team to coordinate care for RFHN patients post discharge from inpatient and Emergency Department (ED) care and/or with complex medical conditions with co-morbidities, in order to reduce ED utilization and inpatient readmissions and to improve health outcomes. The span of the role includes ensuring a patient-centered comprehensive, integrated approach to care across ambulatory and inpatient care. Care will be provided under a comprehensive patient-centered health home framework that is provider led, integrates and coordinates internal and external services and aims to deliver better care at lower costs leading to better health outcomes.


To be performed in accordance with RFHN Policies and Procedures

    1. Helps develop care management systems to document, monitor, track, and evaluate patient interventions across various organizations, inpatient, and primary care settings. 
    2. Acts as clinical lead for care management team needs. 
    3. Provides guidance, training and support in care coordination/ transitions of care to nursing staff and clinical team. 
    4. Serves as care coordination mentor to nursing staff, health coaching and MA staff.
    5. Works with eligible patients to perform both initial and transitional assessments and develops realistic care management plans.
    6. Incorporates knowledge of nursing care management, levels of care, and utilization management principles to implement high-quality cost-effective care.
    7. Establishes a consistent communication and reporting schedule for periodic contact with the patient’s PCP, specialists, community care providers and patients to review patient status and progress toward goals.
    8. Provides care coordination intervention and follow-up for RFHN patients prior to and after interaction with health care system, e.g. inpatient, ED visit, outpatient specialty and in-home care services, etc.
    9. Communicates with social service staff and health care clinicians, about patient’s care, utilization, and follow up plans, e.g. ED Care Facilitators, inpatient Care Coordinators, post-acute case managers, social workers, patient navigators, etc.
    10. Attends and presents case reviews at practice meetings, program meetings, and care coordination meetings. 
    11. Ensures that appropriate data is documented in structured fields to support information tracking to meet the various reporting requirements.
    12. Acts as clinical resource person for program’s quality improvement efforts.
  • Keeps current with related trends in care coordination across institutions.
  • Acts as liaison between clinical staff, providers, social services staff, behavioral health staff, patient and community partners.
  • Other duties as assigned.


  • Completion of COVID-19 vaccine series and booster 
  • Graduate of an accredited RN program, current California RN license and good standing with the Board of Registered Nurses required.
  • At least two years of RN work experience in a general medical inpatient or outpatient setting 
  • Experience in care coordination across institutions and managed care preferred.
  • Quality improvement background preferred.
  • Bilingual English/Spanish fluency required.
  • Current BLS certification required.
  • Experience in a community clinic setting strongly preferred.
  • Experience with providing health education in the management of chronic diseases.
  • Experience working in an electronic medical record environment highly desirable.
  • Ability to memorize, retain and recall pertinent skills and information.
  • Solid personal computing skills, including Microsoft Office (Word, Excel and PowerPoint) to support data collection and reporting.

Ravenswood Family Health Network is an equal opportunity employer.

Qualified applicants, please submit resume to resumes@ravenswoodfhc.org or fax to 650.321.8576.

Note:  Only qualified applicants will be contacted.  Please do NOT contact HR to ask for the status of your resume as those calls will not be returned.

To apply for this job email your details to resumes@ravenswoodfhc.org