Engage patients through scheduled telephonic and virtual care encounters Support patients participating in Chronic Care Management (CCM), Transitional Care Management (TCM), and Remote Patient Monitoring (RPM) programs Provide education regarding chronic disease management, medications, preventive care, and wellness goals Review patient-reported concerns and escalate clinical issues according to established protocols Assist with care coordination activities, including referrals, follow-up appointments, and post-discharge outreach Promote patient adherence to prescribed treatment plans and self-management strategies Maintain accurate and timely documentation in accordance with CMS, payer, and organizational requirements Partner with pharmacists, providers, and care team members to improve patient outcomes and engagement Contribute to quality, compliance, and patient satisfaction initiatives. Active New Jersey LPN license in good standing Minimum two (2) years of nursing experience in ambulatory care, primary care, chronic disease management, telehealth, care coordination, or related clinical settings Strong communication, patient engagement, and documentation skills Ability to assess patient needs and identify concerns requiring escalation Proficiency with electronic health records and web-based clinical platforms Ability to work independently while maintaining productivity and quality expectations Dedicated HIPAA-compliant home workspace with reliable internet access.