• Conduct comprehensive health assessments of members enrolled in healthcare programs through telephonic and/or digital tool interactions. • Gather relevant medical, social, and lifestyle information to develop a holistic understanding of each member’s current status. • Identify potential key risks, gaps in care, and opportunities for enhancing well-being. • Provide telephonic and/or digital education, nursing interventions, and coaching to members on various health topics, including chronic disease management, preventive care, and healthy lifestyle choices. • Empower members to take an active role in managing their health by providing them with the knowledge and tools needed. • Collaborate with members to set achievable health goals and develop personalized action plans. • Coordinate with healthcare providers and community resources to facilitate access to necessary services and support. • Facilitate referrals to internal multidisciplinary care team members including Health Management Nurses and Resource Specialists. • Assist members in navigating the healthcare system, including understanding insurance coverage and finding appropriate providers and resources. • Regularly monitor individuals' health status and progress towards their health goals through telephonic and/or digital tool check-ins. • Provide ongoing support, encouragement, and accountability to individuals to help them stay on track with their health management plans. • Collaborate with healthcare providers to ensure continuity of care and timely interventions when necessary. • Maintain accurate and up-to-date documentation of telephonic and/or digital tool interactions, assessments, care plans, and outcomes. • Ensure compliance with privacy and confidentiality regulations, including HIPAA guidelines. • Ensure adherence to quality benchmarks and standards in all documentation, maintaining accuracy, clarity, and compliance with organizational guidelines. • Demonstrate timely completion of case management activities in alignment with organizational protocols and NCQA accreditation standards, including documentation, care planning, and follow-up within required timeframes. • Perform additional duties as assigned based on the evolving needs of the business.