• Assess members to identify their strengths, interests, and preferences, focusing on health and safety needs to develop a comprehensive Member Care Plan (MCP) • Coordinate services that address members’ health and safety needs, ensuring support is provided in the least restrictive environment in accordance with the MCP • Collaborate continuously with a Field Care Nurse (RN) to review and update care plans and address members’ evolving needs • Conduct face-to-face social assessments with members upon enrollment and at minimum, every six months • Schedule, conduct, and document quarterly in-person visits and maintain monthly contact with members by phone • Identify, arrange, and monitor support services for members, including those related to social integration, community resources, employment, housing, and other non-medical needs • Engage in clear and empathetic communication with members to better understand their needs • Maintain accurate and timely documentation of activities, including case notes, service authorizations, and updates to the Member Care Plan • Foster direct collaboration with service providers, natural supports, and other community partners to enhance member outcomes