Engage patients and community members in identifying lifestyle modification opportunities, establishing goals and action plans, and conducting follow-ups to support healthy, sustainable behavior change. Responsible for contacting patients eligible for the program for enrollment and providing necessary wellness coaching to reduce or eliminate high-risk behaviors, improve self-management of their chronic condition, reduce the risk of admission or readmission into the hospital and improve overall health and well-being of the patient. Support individual patients with complex needs over a designated period, including hospital and possible home visits, follow-up phone calls, and emails, to decrease and/or prevent hospital admissions/readmissions and improve quality of life.