• Performs primarily face to face and telephonic assessments to adult and pediatric members • Evaluates member's needs to achieve and/or maintain optimal wellness • Employs a variety of strategies, approaches, and techniques to manage a member's health issues • Identifies and resolves barriers that hinder effective care • Ensures members are progressing towards desired outcomes by continuously monitoring care through use of assessment, data, conversations with member, and active care planning • Responsible for managing a case load and completing assessments with members in their home or community-based setting, as well as telephonically • Provides clinical support and guidance, particularly for members with medical complexity • Develops and coordinates care plans ensuring that patients receive appropriate services to manage their health needs effectively • Addresses barriers to health care and advocating for optimal member outcomes • Reviews, assesses, and completes medical complexity attestations and clinical oversights • Ensures members are receiving services in the least restrictive setting to achieve and/or maintain optimal well-being by assessing their care needs • Develops and modifies Individual Care Plan and involves applicable members of the care team in care planning • Collaborates with Community Health Workers (CHW), Housing Specialist and other internal and external agencies for HRSN needs • Primary point of contact for the ICT and shall be responsible for coordinating with the member, ICT participants, and outside resources to ensure the member’s needs are met.