Create a positive experience and relationship with the member Help member set goals and develop a care plan to achieve those goals Proactively engage the member to manage their own health and healthcare Support the member to improve their wellbeing by staying out of the hospital, and attend regular visits to their primary physician As needed, help the member engage with mental health and substance use treatment Support the member to ensure pick-up of their prescriptions Provide member education on community resources and benefits Conduct post discharge activities from hospital facility and support connection to social services Support member to engage in work or volunteer activities, if desired, and develop stronger social supports through deeper connections with friends, family, and their community Partner with care team (community, providers, internal staff) Knowledge and continued learning of community cultures and values May conduct Health Risk Assessments (HRA) if needed Performs other duties as assigned