Assess member needs in physical health, mental health, SUD, oral health, palliative care, memory care, trauma-informed care, social supports, housing, and referral/linkage to community-based services. Oversee the development of client care plans and goal setting. Offer services where the member resides, seeks care, or finds most easily accessible. Connect clients to other social services and supports. Advocate on behalf of the client with healthcare professionals. Utilize evidence-based practices like Motivational Interviewing, Harm Reduction, and Trauma-Informed Care principles. Conduct outreach and engagement activities for linkage to ECM program and log activity in CRM system. Evaluate client progress and update SMART goals. Provide mental health promotion. Arrange transportation. Complete all documentation, including outcome measures, within established timeframes. Maintain up-to-date patient health records in EMR and other business systems. Complete monthly reporting for program compliance. Attend assigned training.