• Conducting health risk assessments, coordination of care, and care management for MAPD, C-SNP, and D-SNP members. • Performs assessments of members, including Health Risk assessments per CMS regulation • Follows the patient through various transitions of care to ensure that any gaps in treatment plans are identified and remedied, and promote efficient health care delivery. • Participates in assessment activities to develop individualized care plans in coordination with the patient, family, and providers. • Applies case management standards of practice to focus on effective care of high-need members. • Serves as a member advocate and resource, and provides critical information and recommendations to the rest of the care team. • Maintains strong knowledge of Case management, community resources, and plan benefits to promote improved member experience and health outcomes. • Works collaboratively with the member (and caregivers), primary care physicians, specialists, and other care providers to ensure member compliance and adherence to the medical plan of care. • Assists the Health Services Team in implementing best practices for chronic care and disease management. • Follows standard protocols, processes, and policies. • Provides member education to assist with self-management and encourages members to make healthy lifestyle changes. • Makes referrals to outside sources. • Documents and tracks clinical reviews, member care plans, referrals, and findings. • Performs other duties, projects, and actions as assigned.