• Participate in activities related to care management program build, implementation, oversight, and delegation. • Assist in ensuring compliance with CMS SNP Model of Care (MOC) expectations, NCQA standards, and Medicare Advantage regulatory requirements. • Perform psychological, social and economic care management interventions for members with severe/persistent mental or emotional disorders. • Perform telephonic behavioral health comprehensive assessments of members’ environmental, behavioral, psychological, economic and social factors. • Assist in the development of individualized and culturally sensitive care plans in collaboration with the member’s assigned CM, identifying problems, interventions, barriers and goals. • Performing telephonic re-assessments, care plan revisions and evaluating the effectiveness of the members’ care plan. • Member of the ICT for members with SDOH and BH needs and participates in ICT meetings when appropriate. • Recognizes early signs of a members’ decompensation that requires immediate case management intervention that promotes and motivates compliance with treatment plan. • Serves as an additional point of contact during transitions of care. • Co-manages member cases with the CM to address psycho-social, economic and cultural issues that may impact the members’ care needs. • Serves as a primary socio-economic resource for the D-SNP Care Management Team. • Documents in the members’ case accurately and timely to ensure coordination of the members’ care needs. • Adheres to all CMS, Code of Federal Regulations, local/state/national regulatory requirements and guidelines as well as those outlined within the MOC. • Collaborate with all members of the interdisciplinary care team to facilitate appropriate community resource assistance for members with identified needs. • Screens, identifies, diagnoses, treats and manages mental health and/or substance abuse problems in patients and family members. • Knowledge of hospital, medical center and/or health system resources to access and provide for patient care needs. • Maintains a working knowledge of community agencies and resources and serves as a liaison between them and the healthcare system. • Collaborates for appropriate resource and financial management which may include but is not limited to-financial assistance coordination/referrals, entitlement program coordination/referrals, or patient benefit coordination.