• Conduct virtual, telephonic, and in-home assessments to evaluate members’ physical, mental, and social needs • Create individualized care plans that address social determinants of health, barriers to care, and wellness goals • Provide supportive counseling, care navigation, and referrals to community, and behavioral health resources • Coordinate Medicaid benefits for members • Promote Advance Care Planning and end-of-life care discussions • Document all interventions with timeliness and accuracy • Partner closely with RN Case Managers and the full Interdisciplinary Care Team (ICT) • Act as a liaison between members, families, providers, and community agencies • Support members during major transitions, including hospital discharges, home health referrals, and hospice