• The Care Advocate is an integral part of the member’s care team and works closely with the clinicians and the clinical operations team. • Support our Care Delivery program (WiderCare+), using approved curriculum to build trust and promote health, while simultaneously driving the Community Health Integration (CHI) and Principal Illness Navigation (PIN) programs. • Execute person-centered care plans for patients with serious, high-risk illnesses. • Assist in monitoring and revising disease-specific plans, especially when frequent adjustments in medication or treatment regimens are required. • Act as the link between the patient and the billing practitioner. Support care coordination by managing provider availability, rescheduling, and providing post-hospital discharge support. • Conduct person-centered assessments to understand the patient’s social and cultural context. Identify unmet social needs and develop action plans to address them. • Assist patients and caregivers in navigating the Nashville healthcare landscape. Teach self-advocacy skills to help patients communicate effectively with specialists. • Support patient communication templates and automation. Coordinate with the tech team to handle technical troubleshooting and update patient charts. • Refer patients to supportive services and community-based resources. Establish partnerships with local Nashville organizations. • Use motivational interviewing and capacity-building to help patients manage stress. Provide tailored education to improve treatment adherence.

• Execute person-centered care plans for patients with serious, high-risk illnesses. • Act as the link between the patient and the billing practitioner. • Conduct person-centered assessments to understand the patient’s social and cultural context. • Assist patients and caregivers in navigating the Pennsylvania healthcare landscape. • Support patient communication templates and automation. • Refer patients to supportive services and community-based resources. • Use motivational interviewing and capacity-building to help patients manage the stress of chronic illness. • Maintain detailed logs of all interactions, including the amount of time spent and specific activities performed.

• Principal Illness Navigation (PIN): Execute person-centered care plans for patients with serious, high-risk illnesses. Assist in monitoring and revising disease-specific plans. • Clinical Care Bridge: Act as the link between the patient and the billing practitioner. Support care coordination by managing provider availability, rescheduling, and providing post-hospital discharge support. • SDOH Assessment & Goal Setting: Conduct person-centered assessments to understand the patient’s social and cultural context. Identify unmet social needs and develop specific action plans to address them. • System Navigation & Advocacy: Assist patients and caregivers in navigating the California healthcare landscape. Teach self-advocacy skills to help patients communicate effectively with specialists. • Technical & Workflow Support: Support patient communication templates and automation. Coordinate with the tech team to set up workflows and update patient charts. • Resource Coordination: Refer patients to supportive services and community-based resources. Establish and maintain partnerships with local California organizations. • Behavioral & Social Support: Use motivational interviewing and capacity-building to help patients manage the stress of chronic illness. • CMS Compliance & Documentation: Maintain detailed logs of all interactions, ensuring all documentation meets required standards.

• Conduct initial telehealth visits with enrolled members, assessing medical needs, care gaps, and barriers to accessing care • Build and develop a high-performing clinical team, providing mentorship and professional development to foster long-term growth and leadership within the organization • Establish clear clinical plans and care priorities, and collaborate with the care team for smooth handoffs • Clinical oversight and QA: Audit clinical documentation to ensure compliance with community health billing and program requirements, and that social-determinants sequencing is logical and actionable • Physician training and management: Serve as the primary clinical point of contact for our physician team — onboard new clinicians, deliver feedback, lead re-training, and ensure alignment with company values • Appointment and workflow management: Help structure scheduling, intake, SMA logistics, and clinical workflows to scale efficiently across markets • Policy iteration: Identify broken processes in the field and rapidly iterate on clinical policies, intake forms, and care plan templates • Metric stewardship: Track and report on key clinical KPIs including ER diversion rates, care gap closures, and SDoH resolution • Partner with Area Managers and LCSWs to bridge medical providers and Community Health Workers, ensuring the team operates as a unified care engine • Provide clinical insight to refine program workflows as we scale