Assess, plan, and implement care strategies that are individualized by member and directed toward the most appropriate, lease restrictive level of care. Identify and initiate referrals for member transition to community request and provide assist with social service programs, including financial, psychosocial, community and state supportive services. Manage the care plan throughout the continuum of care as a single point of contact. Communicate with all stakeholders for the required health-related information to ensure quality coordinated care and services are provided expeditiously to all members. Advocate for members and families as needed to ensure the member’s needs and choices are fully represented and supported by the health care team Visit Medicaid members in their homes and/or other settings, including community centers, hospitals, or providers' offices.