Operating within the plan's CMS- and NCQA-approved Model of Care (MOC), this role assesses members' social, financial, and environmental needs; develops individualized care plans; facilitates referrals to community resources; and collaborates with healthcare providers, the Interdisciplinary Care Team (ICT), and community organizations to support member well-being. Coordinate access to community resources, including housing, transportation, food assistance, financial aid, caregiver support, and other social services, providing warm handoffs and following up to confirm members successfully connected with services.