Performs enhanced annual wellness visits or Comprehensive Health Evaluations (CHEs) to identify and evaluate patients' co-morbid conditions and identify and assist with patients' needs, including but not limited to medical, social, emotional, and financial concerns through medical record review, consultation with patient, family, and healthcare team members. Manages the care of CKD/ESKD patients, focusing on delaying disease progression (CKD), medical cost/utilization and preventing/reducing hospitalizations, through proactive post-discharge planning and follow-up with patients most at risk.