RESPONSIBLE TO:  Program Director, Community Health Home

COMMITMENT (HOURS): Full-Time, 40 hours per week

STATUS: Exempt (6 months orientation period)


Family Bridges, Inc., a nonprofit multi-service community based organization located in Oakland Chinatown, is looking for a full-time Nurse Navigator/Care Manager to join our innovative Community Health Home (CHH) program. CHH is a Community Based Care Management Entity (CB-CME) serving the most vulnerable members of our community. The successful candidate is committed to treating each client with respect and dignity, and instilling hope for their own optimal health and well-being. The successful candidate thrives in a positive, team-driven environment, and enjoys working with frail older adults, persons with complex chronic medical conditions, disabilities or special needs, and/or people facing houselessness, substance abuse, or mental health issues.

JOB SUMMARY: The Nurse Navigator/Care Manager supports the most vulnerable members of our community discover options to a wide range of social determinants toward their health and well-being. The Nurse Navigator/Care Manager will serve as an integral team member, assist with managing day-to-day operations, and be responsible for: care management, coordination and clinical consultancy; serving as a liaison and intermediary between medical, behavioral health, social services and the community; facilitating access to services and resources (housing, transportation, healthcare); stabilizing and ensuring clients achieve a safe, stable and healthy living environment. Interactions with clients are performed onsite at Family Bridges and/or in clients’ current place of residence, including hospitals, skilled nursing or other care facilities, houseless residence or encampments, and temporary or transitional housing.


  • Assess, diagnose, plan, implement, and evaluate clients’ physical health, behavioral/mental health, and social needs.
  • Outreach and engage eligible CHH clients.
  • Utilize motivational interviewing and trauma informed care practices to provide client-centered care and establish a health action plan with the client, family and/or caregiver.
  • Provide health promotion, health education, and self-management materials and training to clients, family, and/or caregiver.
  • Serve as a client advocate and liaison between clients, family and/or caregiver, and client’s health plans and other providers.
  • Collaborate and effectively communicate with hospital personnel, discharge planners, health plan personnel, hospice providers, nursing facilities and community resources.
  • Solicit client, family and/or caregiver needs and concerns, and connect them to support resources, such as training sessions, support groups, respite care, etc.
  • Ensure client appointments, transportation, medication, medical supplies and equipment, and meals are arranged as appropriate and needed.
  • Advocate for and recommend resources to achieve a safe and healthy living environment, including housing, food security, and financial and legal assistance.
  • Build collaborative relationships and constructive channels of communication with and facilitate access to clients’ PCP, other physicians, and network of community-based services.
  • Maintain client list/roster, and track progress, interventions, and outcomes.
  • Participate in programmatic internal and external meetings, trainings, and collaborations, including but not limited to preparing and presenting cases during care conferences, as well as contributing to discussions, goal setting and outcomes, and problem solving.
  • Assist in the development, implementation and/or adherence to agency, programmatic, and HIPAA policies, procedures, protocols and workflows.
  • Conduct blood pressure clinic and health education for senior residents of partner agency Hotel Oakland.
  • Provide supervision, leadership and/or training for other program staff and/or interns.
  • Perform other duties as required.


  • Minimum a Bachelor’s Degree in Nursing or Bachelor’s degree in Social Work or related field
  • Minimum of two years community based work experience navigating: Medi-Cal managed care systems; social services systems and benefits; Social Security Administration, DMV, housing authority and other governmental systems; services for the houseless and low-income seniors and other adults suffering from multiple chronic conditions, serious mental illnesses, substance use.
  • Experience managing a caseload of 25-35 complex care clients.
  • Excellent oral and written communication skills in English.
  • Aptitude to work under pressure in an empathetic and professional manner.
  • Strong interpersonal skills, flexibility, and demonstrated ability to work well independently and as part of a team.
  • Familiarity and ability to travel locally in Alameda County, and particularly Oakland.
  • Valid California driver’s license.


  • Familiarity with Alameda County Care Connect/Whole Person Care and Health Homes programs and CB-CME program of Alameda Alliance for Health and Anthem Blue Cross.
  • Work experience with providers and community resources in Oakland, CA or Alameda County
  • Experience utilizing Salesforce platforms, Alameda County Care Connect Community Health Record, and/or Homeless Management Information System (HMIS – Coordinated Entry System).
  • Experience providing housing navigation services, including but not limited to: document readiness; housing application submissions; tenancy rights and low-income housing resources; housing solutions and problem solving in partnership with landlords and/or property managers.


  • Ability to communicate clearly with others.
  • Ability to see and hear in order to interact with others.
  • Ability to use a computer as well as smartphone and/or tablet (e.g. iPad).
  • Ability to travel locally multiple times a day and perform responsibilities in various environments multiple times a day.
  • To lift a minimum of 20 lbs.
  • Vision 20/20 with correction.

SALARY RANGE:  Salary depending on qualifications and experience, plus benefits

TO APPLY: Send, fax or e-mail resume and cover letter to: Human Resources, Family Bridges, Inc.,
168 – 11th Street,  Oakland,   CA 94607,    Fax: (510) 839-2435

Family Bridges, Inc. is a non-profit multi-services community based organization that has been serving the Asian American communities in the East Bay for more than 50 years. Family Bridges is an equal opportunity employer regardless of race, color, religion, sex, national origin, marital status, sexual orientation, age or disability.