The Care Manager provides ongoing support and expertise through comprehensive assessment, planning, and implementation of the provider-patient care plan and overall evaluation of individual patient needs and barriers to care. The Care Manager promotes patient-centered and team-based care through effective communication with patients, the care management team, medical team and center staff. The Care Manager promotes continuity of care through support in navigating the health system, initiating and following up on referrals, providing outreach to patients who are due or overdue for services, coordinating patient education and case managing high-risk patients. The Care Manager is also responsible for keeping resources up-to-date and providing monthly reports on center-specific care management data. Needs to be able to attend monthly meetings on and off site and provides Care Management coverage when needed.