Develop and implement individualized, person-centered care plans and service plans inclusive of goals, opportunities and interventions/servoces aligned with a person's readiness to change to support the best health and quality of life outcomes by meeting the members where they are. Provide referrals and linkage as appropriate and accepted by member (may include internal consult opportunities such as Housing Navigator, Pharmacy Team, Peer Specialist, etc. or community-based provider referrals such as PCP, specialists, medication assisted therapy referrals, etc.).