• Innovations Care Manager (Innovations CM) is responsible for providing proactive intervention and coordination of care to eligible Vaya Health members and recipients to ensure that these individuals receive appropriate assessment and services. • The Innovations CM works with the member and care team to alleviate inappropriate levels of care or care gaps through assessment, multidisciplinary team care planning, linkage and/or coordination of services needed by the member. • Innovations CMs support and may provide transition planning assistance to state, and community hospitals and residential facilities and track individuals discharged from facility settings. • Ensures identification, assessment, and appropriate person-centered care planning for members. • Links members with appropriate and necessary formal/ informal services and supports across all health domains (i.e., medical, and behavioral health home). • Meets with members to conduct Health Risk Assessments (HRA) and gather information on their overall health, including behavioral health, developmental, medical, and social needs. • Administer various screenings within their scope based on member’s needs. • Supports the care team in development of a person-centered care plan (“Care Plan”) to define what is important to members for their health and prioritize goals. • Reviews clinical assessments conducted by providers and partners for clinical consultation as needed. • Proactively ensures that individuals identified with treatment needs have a Behavioral Health Clinical Home and a Medical Home. • Provides crisis intervention, coordination, and care management as needed.