• Engage target members (those who are facing medical, mental health and/or substance utilization disorders) and build a relationship that will support open and constructive dialog on sensitive topics. • Conduct initial holistic health assessments that help build an understanding of a member’s specific situation and needs and identify any social determinants of health (SDOH) and cultural influences that may impact potential lifestyle changes. • Create a space where a case manager and member can collaborate, along with relevant caregivers and providers, to develop a member-centric case management plan that sets goals, addresses potential barriers, and leads to improved health outcomes. • Monitor, evaluate, and update the effectiveness of the member's case management plan to ensure progress toward goals is being made and that current goals remain pertinent. • Facilitate communication and coordination among the health care team to maximize delivery of appropriate care. • Provide interventions focused on removing barriers, promoting positive behavior change using motivational interviewing techniques, and stabilizing the members’ natural support systems by ensuring that caregiver needs are identified and being met. • Maintain concise, accurate, and timely documentation that meets accreditation, contractual, and legal requirements.