While living and demonstrating our Core Values, the Care Gap & Chronic Care Nurse Navigator will: Conduct comprehensive monthly outreach to a dedicated panel of at least 40 Chronic Care Management (CCM) patients, assessing health status, evaluating treatment adherence, and providing health coaching. Collaborate with patients, primary care providers, and the care team to establish, implement, and update personalized care plans for complex chronic conditions (e.g., diabetes, hypertension, COPD, CHF).