Locate, outreach and engage members within the community that clinicians and care navigators have not been able to reach; create a positive experience and relationship with the member Assesses functional and social needs of members and collaborates to develop and implement solutions with the frequency established in the model of care Work collaboratively the multidisciplinary team to engage resources and strategies to address medical, functional, and social barriers to care  Works closely with clinicians to help bridge the gap for these previously un - engaged members and members with whom contact was lost Completely and accurately document in patient’s electronic medical record Provide patients and family members with education regarding the need for follow up as appropriate during each patient visit Actively participate in organizational quality initiatives  Participate in collaborative multidisciplinary team meetings to optimize clinical integration, efficiency, and effectiveness of care delivery  Demonstrate a commitment to the mission, core values and goals of UnitedHealthcare and its healthcare delivery including the ability to integrate values of compassion, integrity, performance, innovation and relationships in the care provided to our members