• Conduct Chronic Care Management (CCM) follow-up calls with eligible patients • Build positive relationships with patients and encourage ongoing engagement in their care plans • Accurately document all patient interactions and care activities within established timelines • Maintain and update CCM tracking logs using Google Drive and Google Sheets • Utilize Office Ally as the primary Electronic Health Record (EHR) system • Coordinate patient care activities and ensure all required documentation is complete and compliant • Monitor patient progress and escalate concerns to the appropriate clinical team when necessary • Collaborate with providers and other healthcare professionals to support continuity of care • Maintain strict HIPAA compliance and protect patient confidentiality at all times • Perform additional administrative and care coordination duties as assigned