• Serve as a primary point of contact for patients navigating chronic care programs • Deliver scheduled and unscheduled telephonic or virtual outreach in Spanish and English • Educate patients on medication use, symptom monitoring, nutrition, and lifestyle changes • Review RPM alerts and trends, escalating clinical concerns appropriately • Support post-discharge follow-up and specialty care coordination • Partner with pharmacists, nurses, and care teams to optimize outcomes • Ensure all documentation meets CMS, payer, and internal quality standards • Promote patient trust, activation, and adherence to care plans