Deliver Care Management to Meet Patient Needs - Conduct outreach, check-ins, and comprehensive assessments to identify and meet patient needs via phone calls, SMS, video calls, or in-person encounters (based on patient preference); Assist patients with appointment setting, office visits, social services application, among other requests. Utilize Technology to Document, Track, and Improve Services - Utilize required care management portals for all care coordination and other services provided in a timely manner; meet patient caseload targets and prioritize services according to intensity, need, and required follow-up.