The Nurse Care Manager (NCM) at Heritage Health Network is a frontline care coordinator within the Enhanced Care Management (ECM) team. NCMs 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.

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.