Develops linkages and refers patients for additional service supports Provides timely and appropriate follow up on newly referred clients Provides Health Home Care Management services at community-based locations and within the Sun River health centers Facilitates periodic case record reviews and case conferences with all providers serving the client Provides linkage, coordination with, referral to and follow-up with appropriate ongoing service providers, including mental health and medical specialists Case conferences with interdisciplinary team including but not limited to PCP, substance abuse treatment team, residential, hospital discharge planners, etc., to coordinate care delivery between all linked providers and client Conducts field work to meet their clients in the community Maintains data and case records as required and prepares necessary reports Develops, coordinates and integrates a coordinated care plan in cooperation with the client, the client's family, and/or the other providers serving the patient. Updates plan at specified intervals, and as needed based on changes in client's condition / circumstances Performs and maintains effective care management for a caseload of clients, as assigned, from assessment to discharge Tracks/ monitors client progress and produces/maintains detailed, accurate and timely case notes Maintains updated case records through health home EMR, and coordinates effective electronic communication throughout all provider databases, as needed.