Heritage Health Network

Coordinate care for members with complex needs through outreach, assessment, care planning, and connecting to community resources to improve health outcomes. | Prior healthcare experience, healthcare vocational program graduate, skilled in motivational interviewing, documentation, and care coordination. | The Lead Care Manager (LCM) at Heritage Health Network is a frontline care coordinator within the Enhanced Care Management (ECM) team. LCMs support members with complex medical, behavioral, and social needs by providing whole-person care management. The role focuses on reducing preventable hospitalizations and emergency department visits, improving health outcomes, and connecting members to vital resources in their community. Key Responsibilities Outreach & Engagement • Proactively reach out to assigned members through calls, field visits, and community engagement to build trust and encourage ECM participation. • Establish strong rapport with members using motivational interviewing and trauma-informed approaches. Assessment & Care Planning • Complete comprehensive assessments covering medical, behavioral health, and social needs. • Develop individualized SMART care plans in collaboration with members, setting achievable goals for improved health and stability. • Review and update care plans regularly to reflect member progress and needs. Care Coordination & Navigation • Coordinate medical care and follow-up appointments to reduce gaps in treatment and avoid unnecessary emergency room visits. • Work with hospitals, clinics, and primary care providers to ensure safe and effective transitions of care after hospital discharge, preventing readmissions. • Connect members to community-based resources such as housing, food security programs, transportation, behavioral health services, and other social supports. Documentation & Compliance • Enter all contacts, interventions, and care plan updates into EMR systems (eClinicalWorks experience a plus). • Maintain clear, accurate, and timely documentation that meets Medi-Cal and Managed Care Plan audit standards. Health Promotion & Member Advocacy • Educate members on preventive health measures and encourage them to participate in both primary and specialty care. • Advocate for members by coordinating services across healthcare providers, social agencies, and Managed Care Plans. Requirements Education & Background • Prior experience in a healthcare setting (doctor’s office, hospital, or clinic) required. • Familiarity with eligibility, authorizations, and referrals is essential. • Graduate of a healthcare vocational program (e.g., 4D College, UEI, or equivalent). • Previous roles may include: Medical Assistant, Referral Coordinator, Care Coordinator, Community Health Worker, Patient Navigator, LVN. Core Competencies • Skilled in motivational interviewing, member engagement, and rapport-building with diverse populations. • Highly organized and disciplined in caseload management and documentation. • Effective communicator across interdisciplinary care teams and community partners. • Flexible problem-solver with experience addressing housing, food insecurity, transportation, chronic disease, and behavioral health needs. Values & Motivation • Mission-driven to serve underserved communities and reduce health disparities. • Motivated by performance-based incentives tied to compliance, quality, and member outcomes. • Committed to culturally responsive care, trauma-informed practices, and collaborative teamwork. Benefits Benefits • Health Insurance: Medical, dental, vision insurance and 401(k) • Paid Time Off: Sick time, paid holidays, and vacation time to support work-life balance. • Compensation and Incentives: Competitive salary with annual merit increases and quarterly bonus opportunities. • Flexibility: Work-from-home options for several days a week. • Professional Growth: Opportunities for career advancement and continued professional development. • Career Development: Opportunities for career advancement and professional development