• Provide proactive intervention and coordination of care to eligible Vaya Health members and recipients to ensure appropriate assessment and services. • Conduct Health Risk Assessments (HRA): comprehensive bio-psycho-social assessment addressing social determinants of health, mental health history and needs, physical health history and needs, activities of daily living, access to resources, and other areas. • Administer screenings (PHQ-9, GAD, CRAFT, ACES, LOCUS/CALOCUS) and transcribe member medication lists into Vaya’s Care Management platform to create multisource medication lists. • Support and participate in interdisciplinary care team meetings and comprehensive, person-centered care planning; ensure Care Plans include mental health, substance use, medical, social needs and NCDHHS-required elements. • Provide clinical transition planning assistance to hospitals and residential facilities; track discharges and ensure follow-up aftercare services to prevent rehospitalization. • Coordinate diversion from institutional placement and provide crisis intervention, coordination, and care management in community settings. • Review assessments conducted by providers for clinical accuracy; provide consultation and technical support; engage provider clinical staff to determine clinical appropriateness. • Manage and facilitate Child/Adult High-Risk Team meetings with community stakeholders and partner with other Vaya departments to identify and address gaps in services/access to care. • Maintain electronic AHR compliance and documentation quality; ensure clinical and non-clinical documentation meet federal, state, and Vaya requirements. • Verify member continuing eligibility for Medicaid and proactively address changes in Medicaid county of eligibility. • Participate in required Vaya/Care Management trainings, multidisciplinary huddles, committees, workgroups, and other projects as requested. • Mobile position: work in a variety of locations including members’ home communities and travel within designated counties.