Work with care teams and technology to identify high-risk, high-need patients by helping to implement best practice processes for preventative services, chronic care and disease management. Act as the liaison between the patient, the patient support network, treating physician(s), and ancillary providers utilizing a multi-disciplinary approach to assess, identify, plan, health goal setting and measure optimal clinical outcomes. Provide face-to-face and/or telephonic coaching, support and education. Utilize motivational interviewing and engagement strategies to support overall health, wellness of patients and self-management which includes employing behavior change/motivational interviewing skills to assess readiness, health goal setting short and/or long term needs, engage patient’s plans for change following standard policy and procedures, clinical guidelines and national evidenced-based criteria.