Manage patient census with a resolution-driven approach to close gaps in clinical and non-clinical patient care. Identify and coordinate community resources with patients. Provide patient education and health literacy on chronic condition management. Perform medication management, including identifying concerns, reconciliation, adherence, and coordinating refills. Assist in ensuring timely delivery of services (Home Health, DME, Home Infusion, etc.). Resolve patient questions and create open dialogue. Assist/Manage referrals and appointment scheduling.