• Performs care management duties to assess and coordinate all aspects of medical and supporting services across the continuum of care for complex/high acuity populations • Develops a personalized care plan/service plan for long-term care members • Evaluates the service needs of the most complex or high risk/high acuity members and recommends a plan for the best outcome • Develops and continuously assesses ongoing long-term care plans/service plans • Coordinates and manages as appropriate between the member and/or family/caregivers and the care provider team • Monitors care plans/service plans and/or member status • Monitors member status for complications and clinical symptoms or other status changes • Reviews member data to identify trends and improve operating performance and quality care • Collaborates with healthcare providers as appropriate to facilitate member services and/or treatments • Collects, documents, and maintains all member information and care management activities • Provides and/or facilitates education to long-term care members and their families/caregivers • Acts as liaison and member advocate between the member/family, physician, and facilities/agencies • May perform home and/or other site visits to assess member needs and collaborate with resources • Partners with leadership team to improve and enhance quality of care and service delivery for long-term care members in a cost-effective manner • May precept clinical new hires and provide guidance and support in navigating within a Managed Care Organization (MCO)