- Navigation and management of complex chronic comorbidities
- Creating and implementing 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
- Collaborate with other healthcare professionals to ensure coordinated holistic care
- Screenings & assessments for SDOH and behavioral needs
- Provide clinical / medical education to clients and staff
- Participate in virtual care conferencing
- Update & maintain medical records
- Participate in quality improvement initiatives