Collaborates closely with the interdisciplinary care team (e.g., physicians, nurses, social workers, pharmacists, community health workers) to share relevant information, support care planning, and ensure alignment of services with patient goals and preferences. • Maintains accurate, timely, and comprehensive documentation of patient interactions, care plans, outreach attempts, and resource referrals in the electronic health record and other designated systems; uses data and reports to support panel management and performance improvement activities.