Essential Job Functions: Essential Job Functions: Proactively identify and close care and quality gaps using EHR tools, payer portals, and internal reports Reach out to patients to schedule Annual Wellness Visits (AWVs) and other important preventative services Upload and track quality measures in payer portals with accuracy and timeliness Connect with patients after hospital, ER, or SNF stays to support smooth transitions and reduce readmissions Identify patients in Skilled Nursing Facilities (SNFs) and help coordinate their follow-up care Partner closely with providers, specialists, and care teams to ensure patients stay on track with their care plans Support our Nurse Practitioner by rooming patients, taking vitals, and assisting during visits Help keep schedules running smoothly by coordinating appointments and follow-ups Assist with patient visits, documentation, and education to reinforce care plans Keep documentation clean, accurate, and up to date across systems Support outreach campaigns and population health initiatives that improve community health. Qualifications: Qualifications: What You Bring High school diploma or equivalent (MA certification preferred) 1-3 years of experience in a clinical or ambulatory setting (primary care or population health is a plus) Familiarity with EHR systems and payer portals Experience with value-based care, HEDIS, CMS measures, or care gap management is a strong plus Strong attention to detail and ability to stay organized across multiple priorities Excellent communication skills-you're comfortable and confident connecting with patients A team-first mindset and the ability to thrive in a fast-paced environment You're proactive-you don't wait for gaps, you go find and close them You genuinely care about patients and helping them stay healthy You're a strong coordinator who follows through and gets things done You're comfortable working with data and using it to drive action You enjoy being part of a collaborative, mission-driven team Experience supporting Annual Wellness Visits (AWVs) Knowledge of transitions of care and SNF coordination.