• Monitor and coordinate care plans: Actively oversee patient treatment plans, tracking progress, adjusting interventions as needed, and ensuring patients are consistently supported. • Patient education and engagement: Provide clear, thorough education about patients’ chronic conditions, treatment options, and lifestyle strategies that improve overall health and well-being. • Facilitate provider connections: Coordinate appointments, follow-ups, and referrals, ensuring patients are linked with the right healthcare professionals and services. • Maintain accurate patient records: Keep up-to-date records of patient health information, insurance details, and financial documentation to support care planning and reporting requirements. • Address patient concerns promptly: Respond to patient inquiries and urgent needs with empathy, professionalism, and problem-solving skills to ensure timely resolution. • Develop and assess interventions: Collaborate with care teams to create and refine health interventions tailored to patient needs, monitoring outcomes and adjusting plans as appropriate. • Collaborate across disciplines: Work closely with behavioral health specialists, disease care management teams, home health providers, social workers, and community-based organizations to ensure holistic, coordinated patient care.