For assigned case load, create care plans to address members' identified needs, remove barriers to care, identify resources (internal and external), and conduct a number of other activities to help improve the health outcomes of members; care plans include both long- and short-term goals and plan of regular contacts for re-assessment of progress towards goals. The incumbent conducts outreach to members enrolled in disease management including but is not limited to, developing a personalized care plan, encouraging behavior changes, identifying and addressing barriers, helping members to coordinate care, and identifying various resources to assist members in achieving their personal health goals.