Perform comprehensive evaluations and document findings in a concise/comprehensive manner that is compliant with documentation standards for the Center for Medicare and Medicaid Services (CMS) Performs patient assessments in multiple settings to include but not limited to the patient’s home, the PCP/specialists clinic, hospital, and/or skilled nursing facility as needed Understands and plans to assure services provided work within the boundaries of the  patient’s plan eligibility. Coordinates  identified patient’s needs utilizing federal, state, and local community resources, as available Coordinates with external and internal teams to minimize obstacles and increase in  patient and provider satisfaction Active participation in Performance Improvement (PI) or regional strategic initiatives Active participation in  staff and Interdisciplinary Teams (IDT) meetings Adheres to organizational and departmental policies and procedures Maintains a high level of professionalism and adheres to the WellMed Core Values Assumes responsibility for personal and professional development Ensures licensure, certifications, and annual training are maintained and compliant Maintains knowledge of current health plan benefits Performs other duties as assigned