Work in collaboration with a multidisciplinary team of clinicians as part of the Care Coordination program to provide high quality, outcome-based, patient-centered care for patients to achieve safe transitions of care, improved patient experience, better health outcomes, reduced avoidable cost and utilization, and increased preventative care. Assist high-risk patients address social barriers to care, ensure sustainable connections to health care services, providers, and social supports, and engagement in their plan of care and health outcomes.