• This job assures that members with complex medical and/or psychosocial needs have access to high quality, cost-effective health care. • Assists in the holistic assessment, planning, arranging, coordinating, monitoring, evaluation of outcomes and activities necessary to facilitate member access to healthcare services. • Advocates for the most appropriate care plan using sound clinical judgment; accurate planning, and collaboration with internal and/or external customers and contacts. • Follows established regulatory guidelines, policies, and procedures in relation to member interventions and documentation of activities related to the member’s care and progress across the continuum of care. • Facilitates and/or participates in interdisciplinary and/or interagency meetings, when necessary, to facilitate coordination of services/resources for members. • Communicate effectively while performing customer telephonic interviewing and communication with external contacts. • Maintain knowledge of Medical Terminology and Medical Diagnostic Categories/Disease States. • Educate members to enhance member understanding of illness/disease impact and to positively impact member care plan adherence, pharmacy regimen maintenance, and health outcomes. • Collaborate with Primary Care Physicians, Medical Specialists, Home Health and other ancillary healthcare providers with the goal being to coordinate member care. • Collect member medical information from a variety of sources including providers and internal records and use appropriate clinical judgment, consultation with internal Physician Advisors and other internal cross-departmental consultation to determine unmet member needs. • Work primarily independently to identify, define, and resolve a myriad of problem types experienced by the member. • Develop an individualized plan of care designed to meet the specific needs of each member. • Anticipate the needs of members by continually assessing and monitoring the member’s progress toward goals, care plan status, and re-adjust goals when indicated. • Maintain a working knowledge of available resources for addressing identified member needs and to facilitate proactive and efficient provision of services. • Be knowledgeable of and consider benefit design and cost benefit analysis when planning a course of intervention to develop a realistic plan of care. • Communicate and collaborate with other payers (when applicable) to create a collaborative approach to care management and benefit coordination. • Maintain a working knowledge of available community resources available to assist members. • Coordinate with community organizations/agencies for the purpose of identifying additional resources for which the MCO is not responsible. • Work within a Team Environment. • Attend and participate in required meetings, including staff meetings, internal Rounds, and other in-services to enhance professional knowledge and competency for overall management of members. • Participate in departmental and/or organizational work and quality initiative teams. • Foster effective work relationships through conflict resolution and constructive feedback skills. • Participate in interagency and/or interdisciplinary team meetings when necessary to facilitate coordination of member care and resources. • Attend internal and external continuing education forums annually to enhance overall clinical skills and maintain professional licensure, if applicable.