• Collaborates with members of an inter-disciplinary care team (ICT), providers, community and faith-based organizations to improve quality and meet the needs of the individual, natural supports and the population with culturally competent delivery of care, services and supports • Facilitates communication, coordinates care and service of the member through assessments, identification, person-centered planning, assist the member in creation and evaluation of person-centered care plans • Engage the member and their natural support system through strength-based assessments and a trauma-informed care approach using motivation interviewing • Facilitate regularly scheduled inter-disciplinary care team (ICT) meetings to meet the needs of the member • Develop and regularly update a person-centered individualized care plan (ICP) in collaboration with the ICT • Identify and manage barriers to achievement of care plan goals • Assist with empowering the member to manage and improve their health, wellness, safety, adaptation, and self-care through effective care coordination and case management • Facilitate coordination, communication and collaboration with the member the ICT in order to achieve goals and maximize positive member outcomes • Educate the member/ natural supports about treatment options, community resources, insurance benefits, etc. • Employ ongoing assessment and documentation to evaluate the member’s response to and progress on the ICP • Document care coordination activities and member response in a timely manner according to standards of practice and CareSource policies regarding professional documentation • Adherence to NCQA and CMSA standards • Perform any other job duties as requested