- Conduct structured monthly outreach calls to monitor patient progress and engagement.
- Verify medication adherence and assist with health risk assessments.
- Support Chronic Care Management (CCM), Transitional Care Management (TCM), and Remote Patient Monitoring (RPM) initiatives.
- Document patient interactions, care updates, and clinical information accurately within EHR systems.
- Coordinate communication between patients, families, providers, and internal care teams.
- Identify barriers to care and escalate patient concerns when necessary.
- Educate patients on care plans, treatment goals, and available support resources.
- Maintain HIPAA compliance and CMS documentation standards at all times.
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