• Serve as a team member on a multidisciplinary D-SNP team, coordinating care, resources and/or services for members to achieve optimal clinical and resource outcomes • Utilize applicable clinical skillset and perform comprehensive assessments to determine how to best collaborate with members, family, internal partners and external services/providers on plans for treatment, appropriate intervention and/or discharge planning • Develop a member-centric plan tailored to members’ needs, health status, educational status and level of support needs; identify barriers to meeting goals or plan of care • Utilize community resources and funding sources as needed in the development of the plan of care • Perform ongoing monitoring and management of member which may include scheduled follow-up with member, discussion of plan with member, appropriate services/education to address needs, appropriate referrals with supporting documentation, assessment of progress towards goals, modification of plan/goals as needed, with contact frequency appropriate to member acuity • Evaluate and facilitate care provided to members through the continuum of care (physician office, hospital, rehabilitation unit, skilled nursing facility, home care, etc) • Educate members and encourage pro-active intervention to limit expense and encourage positive outcomes • Effectively document all aspects of the plan from the initial assessment, development of the plan, implementation, monitoring, and evaluating outcome • May outreach directly to members identified as high risk, high cost, or high utilization cases • May review alternative treatment plans for case management candidates and assess available benefits and the need for benefits exception or flex benefit options, where eligible • May evaluate medical necessity and appropriateness of services as defined by department.