• Manage patient census with a resolution-driven approach to close gaps in clinical and non-clinical patient care. • Identify and coordinate community resources with patients that would benefit their care. • Provide patient education and health literacy on the management of chronic conditions. • Perform medication management, including identifying potential medication concerns, reconciliation, adherence, and coordinating refills. • Assist in ensuring timely delivery of services to your patients; Home Health, DME, Home Infusion, and other critical needs. • Resolve patients' questions and create an open dialogue to understand needs. • Assist/Manage referrals and appointment scheduling.