Provide counseling for patients with chronic illness Develop care plans for patients with quarterly updates Review patient panel and document care activities monthly Coordinate Patient Care Assess health care, educational and psychosocial needs of the patient/family over time Assist patients with self-management through education and telephonic engagement Assist patients by conducting ongoing assessments telephonically, coordinating care conferences with providers and collaborating with the healthcare team Assist patients in navigating the healthcare system Engage patients to actively manage their health using cognitive-behavioral methods, motivational interviewing and mindfulness-based interventions Encourage and support patients to maintain adherence to their care plans Collaborate with the practice care team and specialty care teams Collaborate with PCP, patient and members of the healthcare team, including required health care services outside of Brown Health Medical Group Primary Care Ensure open communication regarding patient status with physicians, office staff and patients'' families Identify and utilize cultural and community resources Act as liaison to hospital, specialists and other health representatives Attend required trainings and practice team meetings as scheduled See patients in the office for consultations and conduct appropriate psychological treatment Perform other job-related duties as required MINIMUM QUALIFICATIONS: Pay Range: $67,724.80-$111,716.80. The core Success Factors include: Instill Trust and Value Differences Patient and Community Focus and Collaborate RESPONSIBILITIES: Identification and stratification of the patient population Identify and stratify the targeted population according to behavioral risk and needs Develop, implement and update patient care plans Manage a panel of patients which includes establishing care management plans, interventions, treatment goals and self-management goals in the areas of depression and anxiety management, smoking cessation, ADHD, 504 plans, coordinate with school based behavioral and educational programs.