• Provide a monthly care management conversation through outbound phone calls to assigned patients to address their healthcare needs. • Communicate resources and services available to patients through the continuum of care. • Identify patient-specific problems, goals, and interventions designed to meet the patient’s individual needs through action-oriented and time-specific goals. • Maintain chart compliance and proper documentation, including but not limited to medical history, medication, immunizations, allergies, surgical history, and family history. • Demonstrate awareness of a patient’s circumstances that may necessitate revisions to care plans, goals, and preferences while being aware of barriers to care and services. • Provide appropriate health education. • Escalate patient concerns to the triage nurse team.