• Develops, assesses, and facilitates complex care management activities for primarily mental and behavioral health needs members to provide high quality, cost-effective healthcare outcomes including personalized care plans and education for members and their families related to mental health and substance use disorder. • Evaluates the needs of the member via phone or in-home visits related to the resources available, and recommends and/or facilitates the care plan/service plan for the best outcome, which may include behavioral health and social determinant needs • May perform telephonic, digital, home and/or other site visits outreach to assess member needs and collaborate with resources • Develops ongoing care plans for members with high level acuity and works to identify providers, specialists, and community resources needed for care including mental health and substance use disorders • Coordinates as appropriate between the member and/or family/caregivers, community resources, and the care provider team to ensure identified services are accessible to members • Monitors care plans/service plans and/or member status and outcomes for changes in treatment side effects, complications and clinical symptoms and provides recommendations to care plan/service plan based on identified member needs • Facilitates care coordination and collaborates with appropriate providers or specialists to ensure member has timely access to needed care or services • Collects, documents, and maintains member information and care management activities to ensure compliance with current state, federal, and third-party payer regulators • Provides education to members and their families on procedures, healthcare provider instructions, treatment options, referrals, and healthcare benefits, which may include behavioral health and social determinant needs • Provides feedback to leadership on opportunities to improve and enhance care and quality delivery for members in a cost-effective manner • Performs other duties as assigned. Complies with all policies and standards.