SummaryServes as a core member of the care team, coordinates and supports healthcare within the facility, and coordinates referrals for services outside the facility. Provides outreach and enrollment services to meet eligibility requirements of the program and surrounding counties. Ensures coordination and planning, including community and family support. Focuses on the development and coordination of community service plans. Partners with service providers, families, and patients to create a plan of healthcare and identify additional service providers.Modify patient treatment plans as indicated by patients' responses and conditions. Prepare patient/family for discharge.Communicates with third party payers to obtain necessary authorization for reimbursement of services. Review cases with medical directors on challenging cases as needed.Defines care goals of patients by providing education, information, and direction to each individual and family. Maintain accurate, detailed reports and records. Communicates with third party payers to obtain necessary authorization for reimbursement of services.