Engage people face-to-face and/or telephonically to complete a comprehensive needs assessment or wellness assessment (as appropriate), including assessment of medical, behavioral, functional, cultural, and social drivers of health (SDoH) Develop and implement individualized, person-centered care plans inclusive of goals, opportunities and interventions aligned with a person's readiness to change to support the best health and quality of life outcomes by meeting them where they are in their health journey. Demonstrated experience / additional training or certifications in care in rural settings homelessness, food insecurity, behavioral health, co-occurring conditions, IDD, Person Centered Care, Motivational Interviewing, Stages of Change, Trauma-Informed Care.