Conduct on-going and effective collaboration and communication with interdisciplinary team including but not limited to, Health Plan Care Team, Community Advanced Practice Clinicians, Community Health Workers, Community Behavioral Health Clinicians, Medical Directors, Palliative Care Team, Psychiatric services team, Rehab Team, Crisis Response workers, Patient Services representatives, administrative staff, and CCA Leaders. The CHW uses evidence-based resources, knowledge of community-based care and support, trauma/recovery skills, and health coaching/education to influence the outcomes of assigned patients by impacting acute care utilization, ensuring optimal treatment and closing gaps in care through connecting patients with community supports.