- Conduct telephonic and virtual care management for patients with heart failure.
- Review and assess patients' medical, functional, and psychosocial needs remotely.
- Reinforce heart failure self-management education.
- Coordinate care transitions between healthcare providers and settings.
- Manage an agreed-upon roster of patients each week.
- Collaborate with providers, specialists, and care teams to optimize patient care.
- Conduct motivational interviewing to encourage lifestyle changes.
- Maintain accurate and timely documentation in electronic health records (EHR).