In collaboration with the person supported, facilitates the Person Centered Planning process that documents the member's preferences, needs and self-identified goals, including but not limited to conducting assessments, development of a comprehensive Person Centered Support Plan (PCSP) and backup plan, interfacing with Medical Directors and participating in interdisciplinary care rounds to support development of a fully integrated care plan, engaging the member's circle of support and overall management of the individuals physical health (PH)/behavioral health (BH)/LTSS needs, as required by applicable state law and contract, and federal requirements. Uses tools and pre-defined identification process, identifies members with potential clinical health care needs (including, but not limited to, potential for high-risk complications, addresses gaps in care) and coordinates those member's cases (serving as the single point of contact) with the clinical healthcare management and interdisciplinary team in order to provide care coordination support.