Locate and engage members within a 60-mile radius of a designated region Assess SDOH needs using a standardized screening tool and coordinate with ICT to identify and connect members to available community resources Engage with members post-discharge from inpatient setting to facilitate connections with community-based services and Peer Support Specialist as needed Provide support to improve medication adherence ensuring access to medications through dispensing pharmacy and facilitating connection to clinical pharmacy programs Proactively provide education and coaching to support self-management of health and care needs as outlined in member’s care plan and in alignment with member-stated goals Partner and collaborate with the ICT, community-based organizations, and inpatient/outpatient providers to ensure members can access medical, behavioral, and substance use treatment services to meet their healthcare needs.  Understand member-specific Medicaid benefits and assist with coordination of applicable services to support care goals and needs Collaborate with clinical team and member to develop both personal wellness plan and crisis plan documents