Serve as primary care manager for high medical risks / needs members with comorbid behavioral health needs  Engage members face-to-face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic (SDoH) needs  Develop and implement individualized, person-centered care plans inclusive of goals, opportunities and interventions aligned with a person’s readiness to change to support the best health and quality of life outcomes by meeting the member where they are  Partner and collaborate with internal care team, providers, and community resources/partners to implement care plan  Provide referral and linkage as appropriate and accepted by member (may include internal consult opportunities such as Housing Navigator, Pharmacy Team, Peer Specialist, etc. or community-based provider referrals such as PCP, specialists, medication assisted therapy referrals, etc.)