• Develops, assesses, plans, implements, and coordinates complex care management activities based on member needs focused on behavioral health needs. • Develops a personalized care plan/service plan as appropriate and educates members and their families on services and benefit options. • Continuously assesses ongoing care plans/service plans of the members via phone or in-home visits. • Identifies providers, specialists, and community resources needed for care including mental health and social determinant needs. • Reviews member data to identify health risks and/or care gaps. • Collaborates with healthcare providers and partners to facilitate care coordination.