Heritagehealthnetwork
Riverside, United States | Posted on 09/16/2025
Heritage Health Network (HHN) was born from a vision to bridge the gap in healthcare accessibility, intuitiveness, and responsiveness. Our founder, a seasoned prosthetist orthotist with over 15 years of experience, leads HHN with a focus on improving health outcomes. HHN emphasizes Enhanced Care Management (ECM) and a holistic, person-centered approach that addresses medical, behavioral, and social needs within the community we serve.
Job Description
The Lead Care Manager (LCM) at Heritage Health Network is a frontline care coordinator within the 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 participation 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 (doctors 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. 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
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The Lead Care Manager (LCM) at Heritage Health Network is a frontline care coordinator within the 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 participation 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 (doctors 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. 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
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