Monitors care plans / service plans and/or member status, change in condition, and progress towards care plan / service plan goals; collaborate with member, caregivers, and appropriate providers to revise or update care plan / service plan as necessary to meet the member's goals / unmet needs. Develops a personalized care plan / service plan for care members, addresses issues, and educates members and their families/care givers on services and benefit options available to receive appropriate high-quality care.