Springfield, MA22 days ago
Principle Responsibilities and Duties: Serve as a direct point of contact for interdisciplinary clinical teams including Primary Care Providers, Nurses, Medical Assistants, Cardiometabolic Team, and Asthma Team to support patients in managing chronic health conditions, including diabetes, prediabetes, hypertension, dyslipidemia, cardiovascular disease, stroke, and asthma. Utilize patient registries to conduct proactive tracking, outreach, and scheduling to engage high- risk patients in primary care and specialty clinics, including Self Monitored Blood Pressure Program, Hypertension Clinic, Asthma Clinic, Spirometry Clinic, Medication Therapy Management Clinic and Diabetes Clinic.