Utilize advanced clinical skills to engage and motivate Consumers via a recovery, health and wellness-oriented approach Assist consumers and their families/caregivers with connections to appropriate psychiatric, medical, and psychosocial referrals and services Identify and remove barriers to procurement, delivery, participation in and success of services Provide supportive follow-up, monitoring and education as indicated, in-person and telephonically Partner with designated external providers, programs, entities to address  the needs, gaps in care, and recovery goals of complex and high risk consumers Identify and address the needs of members who are consistently high utilizers of services through case conferences and informal communications Participate in standing meetings to review performance, identify areas of opportunity, and oversee course for improvements Partner with parents, family and natural community supports to enable children to receive services while remaining in their homes and communities Establish and foster positive relationships with medical team, participate in medical-behavioral integration activities and discussions Identify high-risk, co-morbid needs of consumers Accept referrals via designated processes, collaborate in evaluating available services, and coordinate necessary psychiatric and community referrals, as needed Contribute to treatment plan discussions; routinely attend clinical rounds and other meetings with medical partner or external entities, when applicable Partner with internal Optum Behavioral Health Services Teams to coordinate a seamless transition for consumers from an inpatient setting to community based services Meet all contractual requirements; collaborate early and frequently with other teams in the management of cases stratified as having intensive, complex, and high-risk needs Assist in the development of a relevant and consumer-specific aftercare plan Comply with all policies, procedures and documentation standards in appropriate systems, tracking mechanisms and databases Establish a cooperative relationship with Optum Behavioral Network Services and the Provider community in order to improve access to services and ensure that consumers are served within proper standards of care Collaborate with providers to determine acuity of mental health concerns, barriers and progress; coordinate appropriate services Other duties may apply