• Establish trust and build strong relationships with our patients telephonically and virtually • Interdisciplinary collaboration with the interdisciplinary team (including clinicians, case managers, community health workers, and coordinators) to ensure cohesive, patient-centered care for high-needs patients • Engage with patients to identify social barriers to assist in resource alignment, & coordination services to maximize the effectiveness of the Complex Care Department: Conduct screenings and create personalized action plans tailored to patient’s needs • Recognize caregivers who exhibit signs of burnout or are actively coordinating the patient's care, providing emotional support and additional resources when needed • Assist in navigating complex family/support issues • Facilitate conversations about end-of-life planning • Collaborate with patients to identify their long-term care planning needs and goals. Provide information on available options and support in arranging referrals and coordinating necessary care • Coordinate care between the Devoted Medical Behavioral Health Team and monitor outcomes • Know how to balance multiple competing priorities for complex patients • Build relationships and coordinate with key local market and internal stakeholders