Obtain and review medical history, conduct physical and psychosocial assessments, analyze and diagnose conditions and develop appropriate plan of care Identify gaps in care, interpret diagnostic test and reports and refer appropriately Identify risk factors and help mitigate barriers to access care and reduce risk Develop interventions to assist members in attaining established goals of care Evaluate member’s progress in completion of goals of care and re - assess and assist in care management with members Serves as a key resource on complex and/or critical issues Solves complex problems and develops innovative solutions Establishes and maintains communication and a trusting relationship with the member, family/authorized representative and primary caregiver and specialists Discuss medical options / interventions with members/families to promote understanding and assist them in making informed decisions Clarify member's cultural values that may impact health management / decisions Identify prognosis/trajectory of chronic disease that may impact future member health decisions and conduct advanced care planning discussions 100% travel in local market area to patient’s homes for in home visits