• Provide proactive intervention and coordination of care to eligible Vaya Health members to ensure appropriate assessment and services. • Conduct Health Risk Assessments (HRA) including bio-psycho-social assessment and social determinants of health. • Administer screenings (PHQ-9, GAD, CRAFT, ACES, LOCUS/CALOCUS) and provide education and linkage to supports. • Review and transcribe member medication lists into Vaya’s Care Management platform and support multisource medication list creation. • Develop person-centered Care Plans with interdisciplinary care team and ensure inclusion of mental health, substance use, medical, social needs, and NCDHHS-required elements. • Participate in interdisciplinary care team meetings, present complex cases in multidisciplinary huddles, and solicit input from care team members. • Support transitional care management, diversion from institutional placement, and track discharges for aftercare follow-up. • Provide crisis intervention, coordination, and care management in the community when needed. • Manage and facilitate high-risk team meetings and collaborate with community stakeholders, DSS, DJJ, CCNC, schools, and providers. • Maintain complete and timely documentation in the AHR to meet federal, state, and Vaya requirements and support quality/compliance. • Participate in required trainings and maintain proficiencies; perform other duties as assigned.