• Responsible for the coordination of services for members who meet established criteria, with an emphasis on education/self-management and promoting quality care and cost-effective outcomes • Use a collaborative process to assess Member needs, review options for services and resources, develop and implement a plan of care, coordinate resources, monitor progress, evaluate Member status, discharge Members, and fully document the individualized member care management process and outcome • Address medical, psychosocial, clinical needs, and behavioral health needs including members with mental health and substance use disorder needs • Provide counseling and referrals to community/local/state programs; collaborate with caregivers, providers, community agencies, behavioral health, and other resources to coordinate care to achieve member’s optimal health status • Responsible for the management and oversight of a caseload of moderate - high risk Members with complex medical/behavioral /psychosocial needs