• The Care Manager delivers telephonic care management for Curana patients enrolled in a Value-Based Care Program such as but is not limited to Advanced Primary Care Management (APCM) or Chronic Care Management (CCM) • Working with Curana Providers and the interdisciplinary team, the Care Manager supports quality, cost-effective care • 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 the 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 APCM or CCM • Support quality gap closure through clinical discovery • Schedule 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 • 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 • Primary liaison between the provider and administrative support team.