• Responsible for case management services within the scope of licensure; develops, monitors, evaluates, and revises the member's care plan to meet the member's needs, with the goal of optimizing member health care across the care continuum • Performs telephonic clinical assessments for the identification, evaluation, coordination and management of member's needs, including physical and behavioral health, social services, and long-term services • Identifies members for high-risk complications and coordinates care in conjunction with the member and health care team • Manages chronic illnesses, co-morbidities, and/or disabilities ensuring cost-effective and efficient utilization of health benefits; conducts gap in care management for quality programs • Assists with the implementation of member care plans by facilitating authorizations/referrals within benefits structure or extra-contractual arrangement permissible • Interfaces with Medical Directors, Physician Advisors, and/or Inter-Disciplinary Teams on care management treatment plans • Presents cases at case conferences for multidisciplinary focus. Ensures compliance with regulatory, accrediting, and company policies and procedures • May assist in problem-solving with provider, claims, or service issues.