Conduct monthly Chronic Care Management (CCM) calls and verbal enrollments. Perform Health Risk Assessments, Transitional Care Management, and Remote Patient Monitoring services. Educate patients and families on chronic conditions, medications, and treatment goals. Collaborate with healthcare providers and staff for effective communication and care coordination. Encourage adherence to care plans and support patient self-management. Document all communications and interventions accurately in EHR systems. Comply with HIPAA, CMS, and company quality standards. Maintain productivity and call volume expectations.