- Prepare comprehensive AWV charts supporting provider efficiency and CMS compliance.
- Conduct virtual AWV reviews covering history, medication adherence, and preventive screenings.
- Identify and address patient care gaps and risk factors.
- Provide telephonic and portal-based care management for complex patients.
- Create and monitor individualized care plans for CCM, RPM, RTM, and APCM programs.
- Utilize motivational interviewing to engage patients in care planning.
- Communicate patient status updates to primary care providers and interdisciplinary teams.
- Coordinate orders, referrals, and follow-up actions to ensure care continuity.
- Maintain accurate patient records in electronic health record systems (CT360, RXNT, Zoom).
EHR