• Coordinate and participate in home visits and care conferences involving the member, their supports, and providers. • Coordinate acute and primary care services, care transitions, and related follow-up care. • Conduct in-person comprehensive, strengths-based assessment of the member's outcomes, needs and risks; perform reassessment as condition changes. • Develop, coordinate, monitor and evaluate the members’ outcome-based member-centered plans, considering cost and effectiveness in authorizing services and choosing providers. • Implement risk mitigation strategies to promote the member’s health, safety and independence while respecting the member’s rights to appeal and grieve. • Maintain member records as required by DHS contract and LCI policy. • Build and maintain an effective and collaborative working relationship with Care Manager partner and various departments/stakeholders. • Participate in team meetings and on-going trainings to stay abreast of policies, procedures, and state/federal regulations. • Maintain the confidentiality of member information and protected health information (PHI) in accordance with HIPAA and state/federal regulations. • Provide nursing care in accordance with the Nurse Practice Act.