While performing the duties of this position, the employee is required to travel throughout program settings, resident apartments, agency offices, community locations, and vehicles; climb stairs; sit; stand; walk; bend or balance as needed; use hands to handle documents, medication-related materials, cleaning supplies, phones, computers, and other work tools; and communicate effectively by phone, radio, electronic systems, and in person. Support persons served through self-management education, coordination and monitoring of care, delivery system design, decision support, clinical information systems, and community linkages, while facilitating communication among medical, behavioral health, and community providers to promote continuity of care and address identified healthcare needs.