• Welcome patients into continuous care program(s) and review benefits and services included • Coordinate with the patient’s Respiratory Therapist and pulmonary providers to ensure a collaborate approach to care • Educate patients on the frequency and use of their assigned in-home monitoring devices, if applicable • Create a personalized, comprehensive care plan with the patient via phone or video visits • Identify and address any barriers to patient success • Provide specific education and coaching on patients' chronic pulmonary conditions • Connect with the patient frequently to review readings and update their plan of care monthly • Serve as the patient's first contact for all non-emergent needs (example - medication refills, scheduling, appointment reminders, etc.) • Assist patients in the navigation of their healthcare (example - assisting patients with scheduling appointments, coordinating with specialists, and ensuring preventative screenings are completed, etc.). • Review and evaluate in-home device readings in real time, during normal business hours • Follow established protocols for identifying, communicating and documenting device trends and any associated symptoms in the patient's medical record • Escalate concerning readings and/or symptoms to the provider following a communication protocol established by the provider • Establish a meaningful rapport that builds trust, open communication, and motivation to make a positive change in the patient's health