Routinely check in or schedule appointments with assigned members Maintain documentation of all member encounters to complete established reporting requirements Communicate with providers and care team regarding member progress and care needs Explain and translate information related to the member's care to and on behalf of the member, when necessary Identify and follow up on all referrals made to assure continuity of care and that member/family needs have been met Reassess care plans to ensure effectiveness in achieving desired outcomes for members and their family Address member questions and process member requests in a timely manner Investigate and direct member inquiries or complaints to appropriate staff members, including follow ups to ensure satisfactory resolution Follow established policies to enroll and disenroll members Maintain knowledge of community services and resources available to members including housing resources, financial/income assistance, transportation assistance and food assistance Follow established protocol around patients experiencing pain, safety concerns and/or mental health concerns and creates safety plans, if necessary Recognize signs of child and elder abuse and report appropriately to Child/Adult Protective Services Understand and abide by all departmental and companywide policies and procedures Comply with all safety and injury prevention policies and regulations Perform other duties as assigned or required. Maintain caseload of up to 50 and conduct monthly in-person visits for all members Review and interview potential members to verify eligibility for enrollment in the Health Homes Program (HHP) Complete referral process when necessary Orient and educate members and their families by meeting with them to explain the role of the Care Coordinator Initiate a care plan and provide educational information related to treatments, procedures, medications, and continuing care requirements in coordination with healthcare providers Work with healthcare professionals, community and social support services, and other company employees Document evidence of care in the member's record in a concise and timely manner using the EHR system.