Provide clinical care management services to identified eligible patients; coordinating care and care transitions to obtain desired health outcomes.• o Foster collaboration, shared decision-making, and partnership among clinical and non-clinical care team members.• o Perform patient/family/caregiver outreach according to established protocols.• o Ensures patient eligibility for assigned Home & Supportive Care services and assists with discharge planning and coordination of admissions upon discharge to home, facility or other residence• Identify, enroll, and manage patients in programs for Supportive Care Advanced Illness Management and Transitions of Care.• o Co-manage a diverse population living with one or multiple chronic conditions.• o Collaborate with patient, provider, and care team to develop and implement a plan of care to ensure medically appropriate, cost-effective care• o Identify, execute, and track needed referrals to care and community resources• o Provide resource management to improve care, patient experience and collaborate with Home & Supportive Care providers to effectively implement a patient-centered care plan.• Provide comprehensive care for patients with chronic conditions through Connected Care @ Home remote patient monitoring and make impactful judgment calls using clinical data tools.• o Provide ongoing remote clinical monitoring to patients in partnership with their providers, making informed escalation and triage decisions.• o Collaborate with care team to provide remote clinical monitoring of physiological data based on outlined pathways and ensure seamless care coordination according to each patient’s individual care plan.• o Engage with patients through text and voice/video calls, remotely reviewing patient/client data and health information.•