- Navigate and manage complex chronic comorbidities
- Create and implement treatment plans for patients and family caregivers
- Develop personalized care plans in collaboration with the transdisciplinary team
- Monitor patients’ progress and make necessary adjustments to care plans
- Clinically supervise and collaborate with Care Navigators
- Review, approve, and maintain patient charts and care plans
- Complete accurate clinical documentation and billing for Chronic Care Management (CCM)