Performs assessment, treatment planning, intervention, monitoring, evaluation and documentation on identified High Risk members. Assesses and develops a care plan in collaboration with the admitting, attending and consulting physician, the member and other health care practitioners. Effectively assesses members to ensure provision and transition to an appropriate level of care, to minimize inpatient re-admissions, and to ensure that members’ medical, environmental and psychosocial needs are met across the continuum of care.