Successfully engages member to develop an individualized plan of care in collaboration with their primary care provider and the interdisciplinary team that promotes symptom management, goals of care/advanced directives, healthy lifestyles, closes gaps in care, and reduces unnecessary ER utilization and hospital admissions/readmissions, and manages social determinants of health. Collaborates and facilitates care with the member's primary care provider, UPMC Your Care Interdisciplinary Team, other departments, providers, community resources, and caregivers to achieve desired member outcomes throughout the continuum of care.