Responsible for engaging and enrolling complex patients into services; providing advocacy and case management services; providing specialty services to support a member in becoming "housing-ready" and supporting patients in identifying and obtaining housing opportunities; supporting the development of an interdisciplinary care plan based on identified patient needs; facilitating access to social service resources; monitoring the patient's progress; and problem-solving with patients to accelerate/enhance access to housing and community-based supports. Assists patient in addressing and overcoming barriers with a range of concrete supports, including but not limited to: physical health, behavioral health, financial assistance, child-care and caregiver support, housing, support with utility bills, food, financial entitlements, clothing, transportation, food pantries, violence prevention, social isolation and any other appropriate community resources.