• Manage a defined caseload of enrolled CCM members • Complete required CCM minimum engagement activities and documentation • Conduct proactive outreach based on NP notes and care plan needs • Perform clinical triage for symptom changes, medication questions, and emerging medical concerns • Provide chronic condition education and ongoing clinical support • Coordinate with primary care providers and specialists to support continuity of care • Escalate clinical concerns to the Nurse Practitioner as appropriate • Develop, update, and document individualized care plans • Collaborate closely with the NP and CHW to deliver team-based care • Maintain accurate, timely documentation to support CCM compliance