Conducts comprehensive assessments of physical, behavioral, & long-term care needs; completes nursing assessments, HNAT, HAN, SNF acuity level determinations, completes vendor calls and assigns home health nursing services, addresses and documents any changes in skilled needs; collaborates with interdisciplinary teams to ensure needs are met in the least restrictive environment; evaluates Social Determinants of Healthsuch as social and economic factors, environmental factors, and policies and programs. Documents comprehensive progress notes to include any improvements or declining health statuses; maintains electronic case management records of case-specific documentation; assigns and authorizes services; supports individualized needs based on family dynamics, natural support systems, and environmental factors; completes special projects.