• Schedule patient appointments and send appointment reminders • Handle patient inquiries through phone, email, text, and telehealth platforms • Communicate professionally and compassionately with patients • Manage email and text communications, including sorting, responding, prioritizing, and sending newsletters • Coordinate with healthcare professionals to support smooth patient care • Manage and maintain patient records accurately in AthenaHealth • Support chronic disease management through follow-ups, patient tracking, and record updates • Assist with medical coding and documentation support • Compile medical research and prepare reports as needed • Prepare and organize reports, presentations, spreadsheets, and other documents • Process claims and verify patient insurance coverage • Support medical billing reconciliation • Assist with billing-related administrative tasks • Help ensure insurance and patient financial information is documented accurately • Manage telehealth platforms and virtual patient coordination • Support donor communications using provided templates • Assist with social media management, including content scheduling and account monitoring • Provide general administrative support as the clinic grows and operational needs evolve

• Perform comprehensive initial TOC visits. • Conduct a thorough post-discharge assessment of the patient's medical conditions, medications, functional status, and psychosocial needs. • Complete a full post-discharge medication reconciliation — including identifying duplicate, inappropriate, or contraindicated therapy and optimizing guideline-directed medical therapy. • Place appropriate orders (prescriptions, labs, imaging, referrals, home health, DME), provide disease-specific education, and communicate clear contingency plans and red flags for worsening symptoms. • Perform acute / virtual urgent-care TOC visits. • Independently assess, diagnose, and manage new or worsening symptoms in medically complex patients, determine the appropriate level of care, and escalate when needed — with a clear bias to action. • Manage the clinical trajectory across the 30-day window. • Reinforce and adjust each patient's plan of care in response to their evolving clinical picture, their priorities, and the barriers they face — including chronic disease management, symptom management, and timely changes to the medical regimen. • Participate in interdisciplinary TOC rounds to discuss patients at highest risk of readmission, and collaborate closely with RN case managers, care coordinators, social work case managers, pharmacy, and patients' PCPs and specialists. • Enhance team culture by facilitating safe, open communication across roles and supporting clear patient escalations. • Assist with clinical education of the broader team, participate in quality-improvement projects and pilots, and provide feedback to improve our EHR. • Embrace a build environment. As our service needs evolve, this role may expand to support new clinical and organizational initiatives.

• Perform comprehensive initial TOC visits. • Conduct a thorough post-discharge assessment of the patient's medical conditions, medications, functional status, and psychosocial needs. • Complete a full post-discharge medication reconciliation — including identifying duplicate, inappropriate, or contraindicated therapy and optimizing guideline-directed medical therapy. • Place appropriate orders (prescriptions, labs, imaging, referrals, home health, DME), provide disease-specific education, and communicate clear contingency plans and red flags for worsening symptoms. • Perform acute / virtual urgent-care TOC visits. • Independently assess, diagnose, and manage new or worsening symptoms in medically complex patients, determine the appropriate level of care, and escalate when needed — with a clear bias to action. • Manage the clinical trajectory across the 30-day window. • Reinforce and adjust each patient's plan of care in response to their evolving clinical picture, their priorities, and the barriers they face — including chronic disease management, symptom management, and timely changes to the medical regimen. • Participate in interdisciplinary TOC rounds to discuss patients at highest risk of readmission, and collaborate closely with RN case managers, care coordinators, social work case managers, pharmacy, and patients' PCPs and specialists. • Enhance team culture by facilitating safe, open communication across roles and supporting clear patient escalations. • Assist with clinical education of the broader team, participate in quality-improvement projects and pilots, and provide feedback to improve our EHR. • Embrace a build environment. As our service needs evolve, this role may expand to support new clinical and organizational initiatives.

• Perform comprehensive initial TOC visits. • Conduct a thorough post-discharge assessment of the patient's medical conditions, medications, functional status, and psychosocial needs. • Complete a full post-discharge medication reconciliation — including identifying duplicate, inappropriate, or contraindicated therapy and optimizing guideline-directed medical therapy. • Place appropriate orders (prescriptions, labs, imaging, referrals, home health, DME), provide disease-specific education, and communicate clear contingency plans and red flags for worsening symptoms. • Perform acute / virtual urgent-care TOC visits. • Independently assess, diagnose, and manage new or worsening symptoms in medically complex patients, determine the appropriate level of care, and escalate when needed — with a clear bias to action. • Manage the clinical trajectory across the 30-day window. • Reinforce and adjust each patient's plan of care in response to their evolving clinical picture, their priorities, and the barriers they face — including chronic disease management, symptom management, and timely changes to the medical regimen. • Participate in interdisciplinary TOC rounds to discuss patients at highest risk of readmission, and collaborate closely with RN case managers, care coordinators, social work case managers, pharmacy, and patients' PCPs and specialists. • Enhance team culture by facilitating safe, open communication across roles and supporting clear patient escalations. • Assist with clinical education of the broader team, participate in quality-improvement projects and pilots, and provide feedback to improve our EHR. • Embrace a build environment. As our service needs evolve, this role may expand to support new clinical and organizational initiatives.