Collaborate with member, family, providers, and team members to develop a patient centered, culturally sensitive plan of care supporting patient with self-management goals, remains productive and offers help and support to team members, Coordinates alternative community resources to include Social Determinants of Health needs, home health care, durable medical equipment, meals on wheels, hospice, etc. to promote and assist in keeping the member safe in the environment of their choice and in alignment with the member wishes. Understands how to navigate Care Coordination process of Assessment, Planning, Goal Setting, Intervention, and Evaluation with the ability to utilize these components to provide for the individual health care needs and promote positive outcomes (quality), Initiates, updates, and revises: Assessments, Patient Outreach Encounter documentation and Interdisciplinary Care Plan within the EMR.