• Provide education, referrals, care management activities surrounding available services and supports including Physical Health, Behavioral Health, I/DD, LTSS, TBI, Pharmacy, Vision, and Dental services/supports. • Link to needed behavioral health and physical health care services and facilitating appropriate connections to primary healthcare services through Community Care of North Carolina, the Health Department, or other community health resources • Coordinating and linking members to benefits • Complete initial and yearly Care Management Comprehensive Assessment and Care Plan • Conduct Care Team meetings and ensure treatment team members participate in treatment team meetings to address the needs of the member • Conduct continuous monitoring of progress towards goals identified in Care Plan through in-person and collateral contacts with the member and member’s supports, including family, information and formal caregivers and routine care team reviews • Identify the gaps in needed services and intervene as needed to ensure the member receives appropriate care • Identify and refer member to community resources • Oversee care transitions for members who are moving from one clinical setting to another • Maintain accurate tracking and data information for care management activities and outcomes including tracking of individuals in and out of services, those who are on waiting lists, those who need follow-up, and those on outpatient commitments • Serves as a collaborative partner in identifying system barriers through work with community stakeholders • Manages and facilitates Child/Adult High Risk Team meetings in collaboration with DSS, DJJ, school systems, CCNC Care Managers, and other community stakeholders as appropriate