Lead Care Manager (LCM)

The Bilingual Lead Care Manager partners with Care Team Operations, Clinical Operations, Compliance, Community Health Workers, Behavioral Health staff, and external providers (medical, housing, and social services) to ensure seamless, culturally responsive, member-centered care coordination.  The bilingual LCM additionally supports members with limited English proficiency by facilitating communication, translation, and cultural interpretation as needed.

Responsibilities

• Serve as the primary point of contact for assigned members, building trust and maintaining active engagement through consistent outreach, relationship-based strategies, and a trauma-informed approach. Provide all communication in the member’s preferred language.
• Conduct comprehensive assessments (physical, behavioral, functional, social) and develop person-centered care plans that reflect the member’s goals, risks, preferences, cultural needs, and social determinants of health.
• Implement, monitor, and update care plans following transitions of care, significant changes in condition, or required reassessments; ensure timely and compliant submission of all care plans.
• Coordinate services across the continuum—including medical, behavioral health, housing, transportation, social services, and community programs—to reduce fragmentation and remove barriers to care.
• Conduct required in-person home or community visits based on member need and risk stratification and maintain a compliant monthly visit structure.
• Utilize motivational interviewing, coaching, and health education to promote behavioral change, self-management, and long-term member stability.
• Identify gaps in care, service delays, lapses in benefits, unmet needs, and environmental risks; collaborate with internal and external partners to resolve issues quickly and effectively.
• Maintain accurate, timely, audit-ready documentation of all interactions, assessments, and interventions using required HHN platforms, including eClinicalWorks (ECW), Google Suite, RingCentral, PowerBI dashboards, and payer portals.
• Meet or exceed HHN and payer productivity standards, including encounter metrics, outreach requirements, documentation timelines, and quality measures.
• Actively participate in multidisciplinary case reviews, team huddles, care conferences, and escalations with nurses, behavioral health staff, CHWs, care operations, and compliance.
• Coordinate and schedule appointments with primary care, specialists, behavioral health providers, and community partners; manage referrals, transportation, and follow-ups to ensure continuity of care.
• Support hospital discharge (TOC) planning through follow-up scheduling, care transitions, medication reconciliation support, and education on discharge instructions.
• Assist members in navigating plan eligibility, redeterminations, documentation, social service applications, housing resources, and crisis interventions.
• Maintain active and professional communication with members and care partners through HHN-approved channels, including RingCentral, secure messaging, SMS workflows, and phone.
• Participate in HHN’s continuous quality improvement efforts, identifying workflow gaps, documenting barriers, sharing insights, and contributing to best-practice development.
• Uphold confidentiality and adhere to all HIPAA and payer regulatory requirements across all areas of care delivery.
• Open to seeing patients in their home or their location of preference.
• Provide real-time interpretation and translation support (verbal and written) for members and families with limited English proficiency.
• Help bridge cultural gaps that may impact communication, trust, adherence, or engagement.

Skills Required

Competencies

Job Requirements