• Manage market panels to ensure patients and families are getting the right care at the right time through identification of high-risk patients, admission/discharge/transfer notifications, claims data, and findings from visits with Nest. Aggregate individual family members’ care plans to understand and create a clear plan for the family. Lead interventions and coach Family Advocates on priority interventions. • Identify social determinants of health and work with interdisciplinary team to support family needs and decrease barriers to care. • Through various modalities (in-person, virtual, or by phone) and based on the patient’s plan of care, the NCM will provide timely, relevant, and clear education to improve patient/family understanding of their conditions and how manage those conditions to improve health outcomes. • Act as clinical liaison for payer-based Care Management programs supporting both programmatic and individual patient needs as indicated. • Ensure accountability and follow up for patient care needs through panel management, case studies, and chart reviews. Support intradisciplinary team members on what they need to execute care plans and best support patients. • Use data and reporting to identify gaps in care or services and conduct patient outreach to facilitate follow-up care or services. • Visit, educate, and serve as a resource to providers on patients with chronic and/or high-risk conditions that could benefit from extra services to provide coordination and linkage to general medical service. • Communicate and coordinate with specialists, mental health and nutrition providers regarding Nest patients as needed to ensure patients are receiving the care they need both inside and out of Nest. • Follow-up with patients within a reasonable amount of time that the information regarding inpatient discharge and ED visits information is made available to Nest Health. • Complete chart review and preparation ahead of visits specifically related to hospital utilization, social determinants of health, HEDIS quality gaps, and immunization needs. • Assist in provider efficiency by pending immunizations due for pediatric patients. • Provide feedback and insights on Nest’s care model for continual refinement to best support patient care and employee experience. • Intermittently support field team on field visits to fully understand and appreciate the in-home care patients and families receive. • Collaborate to engage new patients and support outreach efforts. • Other duties as assigned.