- Perform monthly CCM touchpoints for assigned patient panels.
- Build strong, ongoing relationships with patients and caregivers.
- Review patient chart data before calls.
- Conduct structured symptom assessments.
- Evaluate changes in condition using licensed clinical judgment.
- Assess medication adherence issues and side effects.
- Escalate urgent clinical issues via defined triage pathways.
- Collaborate with the provider team on symptom changes and care coordination.
- Document patient interactions in EHR and CCM platforms.
- Track and log qualifying CCM time for billing compliance.