Travel to members' homes, nursing facilities, and other community based settings in order to complete face to face needs assessments with subsequent telephonic contact with the member in accordance with state and national guidelines, policies, procedures, and protocols.

Assess, plan, coordinate, implement and evaluate care for eligible members with chronic and complex health care, social service and custodial needs in a nursing facility or home and community-based care setting.

Coordinate care across the continuum of services and assisting members physical, behavioral, long term services and supports (LTSS), social, and psychosocial needs in the safest, least restrictive way possible while considering the most cost-effective way to address those needs.

Facilitate authorization, coordination, continuity and appropriateness of care and services in community or HCBS.

Facilitate transitions to alternate care settings such as hospital to home, nursing facility to community setting using an integrated care team to address the member's specific needs.

Educate members or caregivers regarding health care needs, available benefits, resources and services including available options for long term care community or facility-based service delivery.

Provide education, resources, and assistance to help members achieve goals as outlined in their plan of care and to overcome obstacles to achieving optimal care in the least restrictive environment.

Develop a plan of care in conjunction with members or caregivers to identify services to meet the member's specific needs, and goals.

Identify resources needed for a fully integrated care coordination approach including facilitating referrals to special programs such as Disease/Chronic Condition Management, Behavioral Health, and Complex Case Management.