• Conducting in-depth telephonic assessments to understand each patient’s medical, psychosocial, and social needs. • Reviewing and updating medical histories—including medications, chronic conditions, and preventive care. • Developing individualized care plans and guiding patients through their treatment goals and care options. • Providing empathetic, evidence-based education on chronic disease management and preventive health. • Monitoring progress by phone, adjusting care plans, and ensuring patients stay connected to their providers. • Completing Medicare Annual Wellness Visits (AWVs) via telehealth under physician supervision. • Partnering with Healthguides who support non-clinical needs like scheduling, transportation, food assistance, and SDOH resources. • Performing proactive outreach and timely follow-ups to maintain continuity of care and patient engagement. • Advocating for patients, helping them access the right resources at the right time. • Documenting clearly and accurately in the EHR and care-management systems during and after calls. • Supporting quality outcomes (HEDIS, NCQA) by coordinating preventive services and managing chronic conditions. • Participating in virtual meetings, ongoing education, and clinical training to stay current with care standards. • Using multiple communication methods (phone, text, patient portals, email, AI-supported tools) to reach high-risk patients. • Collaborating in AI-driven outreach programs that help connect with vulnerable populations. • Protecting patient privacy in a secure, private home workspace. • Performing additional responsibilities as needed to support patients and the care team.