The successful candidate will be willing and able to: Client outreach and engagement, including direct communication with clients such as in person meetings, mail, email, texts and telephone; community and street-level outreach; Complete documentation required for data reporting and outcome tracking; Complete a Comprehensive Assessment by researching and analyzing patient records and interviewing patients and/or caregivers; Develop a Care Management Plan (CMP) that incorporates client's needs in the areas of physical health, mental health, SUD, community-based Long-Term Services Support, oral health, palliative care, social supports, and Social Determinants of Health; Care coordination and organizing client care activities per the CMP and case conferences for care coordination; Maintaining an active panel of 50 members; Sharing and maintaining information with client's multidisciplinary team and implementing activities per CMP, including Community Supports; Support client engagement in support including coordination or medication review and or reconciliation, scheduling appointments, appointment reminders, coordinating transportation, accompany client to critical appointments, identify and address other barriers to client's engagement in services; Ensuring regular contact with the member and their family member(s), guardian, caregiver, and/or authorized support person(s) as part of care coordination; Engage and help client participate in and manage their care; Coaching members to make lifestyle choices based on healthy behavior - goal is for members to successfully monitor and manage their health; Supporting members in strengthening their skills to identify and access resources to assist them in managing and prevention of chronic condition; Linkage to resources based on member's needs such as smoking cessation, self-help recovery, etc. Provide transitional care for clients during discharge from hospital or institutional setting including developing a transition care plan (Targeted Care Plan Update), and coordination of care to provide adherence support and referrals to appropriate resources and community supports, as needed; Identify supports needed for client; Collaboration with Community Supports provider and other community-based organizations to coordinate services; Provide appropriate education of the client and/or their family support/authorized support about care instructions for the person served; Assist members in accessing additional benefits and related documentation such as, Social Security Insurance (SSI), CalFresh, cash aid, and obtaining required documentation to apply (ID, birth certificate, immigration status, financial records, marriage/divorce records, proof of medical conditions, etc.); Develop, establish, and maintain professional and collaborative working relationships with internal and external care team; Network with community and stakeholders to remain current on issues and activities as they impact coordination of care for clients; Coordination of care with health plans; Attend required training to maintain provider certification and current industry knowledge; Perform administrative tasks including timely record keeping and data entry; Maintain up to date, adequate records and other documentation necessary for the collection of data and statistics pertaining to program outcomes, demographics, and information as required by funders; Collaborate as an active member of a team; Actively model and communicate the mission and vision and support a corporate culture of empowerment, team building, and open communication; Maintain compliance with all applicable county, state and federal laws and regulations, funder and program requirements; Perform other duties as assigned.