• Provides telephonic care management to Medicare members with complex and high-risk health needs as part of a multidisciplinary care team. • Conduct proactive telephonic outreach to Medicare members with complex and high-risk medical needs. • Prioritize members recently discharged from the hospital to reduce 30-day readmissions and improve care transitions. • Support members with uncontrolled chronic conditions, including diabetic members with elevated A1C levels, through structured follow-up and education. • Assess member health status through both outbound and inbound calls (average 15–20+ outreach calls per day). • Provide individualized health and disease education using Motivational Interviewing techniques to promote engagement and self-management. • Develop, implement, and monitor personalized, comprehensive plans of care that address medical, behavioral, and social factors. • Perform medication reconciliation and identify potential barriers to adherence or treatment success. • Coordinate services across providers, pharmacies, durable medical equipment (DME) vendors, home health agencies, and community resources. • Collaborate with physicians, caregivers, and interdisciplinary teams to ensure continuity and quality of care. • Identify and address gaps in care across multiple diagnoses and care settings. • Adapt outreach focus and workflow as organizational priorities evolve. • Document member interactions accurately and efficiently in real time within electronic systems. • Participate in new program initiatives and continuous improvement efforts. • Contribute to a highly collaborative and cohesive team environment. • Provide training and mentorship to new team members as appropriate.