- Prepare comprehensive Annual Wellness Visit (AWV) charts to support provider efficiency and CMS compliance.
- Conduct face-to-face virtual reviews with patients via Zoom to summarize health histories, medications, and preventive screenings.
- Develop, implement, and monitor individualized care plans for Chronic Care Management (CCM), Remote Patient Monitoring (RPM), Remote Therapeutic Monitoring (RTM), and Advanced Primary Care Management (APCM).
- Identify and close care gaps such as overdue screenings, labs, and follow-ups to ensure continuity of care.
- Utilize motivational interviewing to engage patients and caregivers in care planning and adherence.
- Communicate patient status and care plan updates to primary care providers and interdisciplinary teams.