• Develops, assesses, and facilitates complex care management activities for primarily physical needs members • Provides high quality, cost-effective healthcare outcomes including personalized care plans and education for members and their families • Evaluates the needs of the member, barriers to accessing appropriate care, social determinants of health needs • Develops ongoing care plans / service plans and collaborates with providers to address member's unmet needs • Identifies problems/barriers to care and provide appropriate care management interventions • Coordinates between the member and/or family/caregivers and the care provider team • Provides ongoing follow up and monitoring of member status and progress towards care plan goals • Provides resource support to members and care managers for local resources for various services • Facilitates care management and collaborates with appropriate providers or specialists • Collects, documents, and maintains all member information and care management activities • Provides and/or facilitates education to members and their families/caregivers on disease processes • Provides feedback to leadership on opportunities to improve care and quality delivery