• Facilitate access to primary care and behavioral health providers, as needed • Responsible for working effectively with and as part of Titanium’s interdisciplinary team to provide high quality and effective care management to members • Engage members in skilled therapeutic interactions to promote health behaviors and/or other behavioral health interventions within scope of practice • Coordinate care using resource linkage and partnering with other professionals and organizations in the community to ensure quality of care for members • Provide seamless transition of care that meets IEHP’s requirements for post ER visits and hospitalizations • Complete regularly scheduled follow-up visits • Provide care coordination through phone calls, emails, messages, updating calendars, scheduling appointments, data entry, and attending meetings • Support the Behavioral Health Care Manager, Community Health Worker, and Care Coordinator with delegated tasks • Collaborate on member care issues with other ECM care team members • Participate in weekly systematic case reviews and ad hoc case reviews • Consult with the Clinical Nurse Leader and/or the Behavioral Health Care Manager before taking any clinical action • Strategize to engage members in care and conduct motivational interviews • Provide health education to members within scope of practice • Initiate a care plan and complete all necessary assessments of healthcare plan guidelines • Understand and abide by all departmental and companywide policies and procedures • Perform other duties and projects assigned