Supports the Patient-Centered Medical Home (PCMH) by working with patients, families, providers and other staff to promote timely access to needed care, provide daily continuity of care coordination, and coach patients, families and care givers to understand the patient care plan and self-care management responsibilities. Ability to communicate clearly in person, on the phone, and via the computer to establish/maintain cooperative relationships with patients, families, physicians, staff and other customers.