**Duties/Responsibilities:**

+ Manages designated caseload of members who could benefit from Peer Support services, care coordination, and health navigation
+ Schedules and conducts multiple field-based visits per day (clustered by geographic areas)
+ Completes assessments and questionnaires to identify barriers and opportunities for intervention
+ Works telephonically when not in the field to make outreach calls and receive incoming calls to/from members regarding benefit questions/issues, care coordination, program inquiries, and connecting to their care manager
+ Generates referrals to providers, community-based resources, and appropriate services and other resources to assist in goal achievement and maintenance of successful health outcomes
+ Liaise between service providers such as doctors, social workers, discharge planners, and community-based providers to ensure care is coordinated and care needs are addressed
+ Collaborate as part of the multi-discip...