Linking members to applicable community resources Complete field visits for high risk, hard to reach members Telephonic outreach to targeted members Keep the member out of the hospital by supporting regular visits to their primary physician Keep member actively engaged with their primary physician Support the member to ensure pick - up of their Rx Proactively engage the member to manage their care Provide member education Support transitions of care Create a positive and engaging experience for the member Help to keep members compliant with their care plans Collaborate with member’s care team (community, providers, internal staff) Partner with and support care team by completing delegated tasks Knowledge and continued learning of community cultures and values Conduct individual-level screenings to capture member's current health care needs (e.g. Transitions of Care, Health Risk assessments) Engage member to participate in the screening process and collaboratively develop plan of care based on their individual needs, preferences, and objectives