The Clinical Care Manager identifies and addresses barriers to optimal self-management and works with the member, their support persons, and team to coordinate care throughout the health care continuum, assisting the member to access all available benefits and resources including family support and community resources, with a goal of promoting appropriate utilization of services at the appropriate level and site of care such as preventing ambulatory sensitive emergency department visits and inpatient admissions, avoiding readmissions, and encouraging the member to keep scheduled outpatient appointments to include preventive care visits. Utilizing both telephonic outreach and face to face member visits and through the use of assessments, real-time data, motivational interviewing techniques and evidence-based practices, the Clinical Care Manager engages with the member and the multidisciplinary team to develop an Individualized Care Plan (ICP) that emphasizes self-management goals, care coordination, psychosocial, socioeconomic, and community-based supports and on-going monitoring and appropriate follow up.