Using a defined process to identify patients/members at risk for poor outcomes, the Care Manager establishes care plans and goals, and coordinates care and services throughout the continuum of care with the goal of maximizing member health and well-being, improving adherence to health programs, and reducing health care costs. The Care Manager works in collaboration and continuous partnership with patients and their family members, as well as pcp, specialists, clinic, hospital, and post-acute partners, along with community resources, to achieve the desired outcomes.