- Coordinating face-to-face visits
- Managing the Elderly Waiver
- Conducting annual assessments including Personal Care Assistance (PCA) assessments for community members and customized living tools for members residing in Assisted Livings
- Reviewing current health needs, identifying goals, and developing individualized care plans
- Helping connect members with community and state resources and services
- Completing required documentation
- Collaborating with medical care teams to ensure health care quality measures are met and use utilization management tools to meet value-based goals
- Supporting members during transitions of care as well as collaborating with their care team to ensure a safe discharge and follow up plan