• The Care Manager delivers telephonic care management for Curana patients enrolled in a Value-Based Care Program • Conduct comprehensive assessments of patients’ medical, psychosocial, and functional status. • Review electronic health records (EHR) to identify gaps in care for patients residing in a Long-term Care Nursing Facility. • Review and approve initial and ongoing health questionnaires completed by a member of Curana’s care management team. • Serve as a health coach to educate patients and/or caregivers about their disease process. • Develop patient-centered care plans. • Educate patients and their durable medical power of attorney (DPOA) on the benefits of GUIDE, APCM or CCM. • Support quality gap closure through clinical discovery. • Recommend Provider visits for at-risk patients • Coordinate with the Transitional Care Manager to schedule patient visits and inform the TCM nurse if a patient is discharged to acute or SNF. • Ensure orders, referrals, and prior authorizations are facilitated by the virtual care support team. • Escalate abnormal diagnostic test results to Curana providers. • Acts as the Clinical Liaison for the non-clinical support staff • Communicate patient health updates to the Curana providers. • Communicate treatment plans and health updates to the patient’s caregiver in an effective and caring manner.