- Support CCM patient enrollment, onboarding, and eligibility verification.
- Conduct high-volume text and telephonic outreach to enrolled patients weekly.
- Reinforce provider-directed care plans and identify barriers to medication adherence.
- Document patient interactions accurately within CCM and EHR systems.
- Track engagement time to ensure compliance with Medicare CCM billing requirements.
- Facilitate patient access to providers and coordinate care transitions.
- Escalate patient symptom concerns or medication issues to clinical staff.