• Assess member needs in the areas of physical health, mental health, SUD, oral health, palliative care, memory care, trauma-informed care, social supports, housing, and referral and linkage to community-based services and supports • Oversees the development of the client care plans and goal settings • Offer services where the member resides, seeks care, or finds most easily accessible, including office-based, telehealth, or field-based services • Connect clients to other social services and supports that are needed • Advocate on behalf of the client with health care professionals (e.g. PCP, etc.) • Utilize evidence-based practices, such as Motivational Interviewing, Harm Reduction, and Trauma-Informed Care principles • Conduct outreach and engagement activities in order to facilitate linkage to the ECM program and log activity in the Client Relationship Management (CRM) system • Evaluate client’s progress and update SMART goals • Provide mental health promotion • Arrange transportation (e.g., ACCESS) • Complete all documentation, including outcome measures within the timeframes established by the individual care plans • Maintain up-to-date patient health records in the Electronic Medical Record (EMR) system and other business systems • Complete monthly reporting to ensure program compliance • Attend training as assigned