The Ambulatory Case Manager is responsible for the assessment, treatment planning, intervention, monitoring, evaluation, care plan development and documentation on identified High Risk patients and other individuals in need of case management within our population. Works in collaboration with Primary Care Providers to review attributed patient rosters, identify at risk patients, review progress of patients under management, and address care coordination needs. Works to close care coordination or clinical gaps in care needs with other members of the care team (e.g., Health Coaches, Care Coordinator, specialists, etc.). Supports CPC practices identify, assess and manage at- risk CPC attributed beneficiaries.