This role is central to the practice’s success in the Accountable Care Organization (ACO) and other value-based arrangements: the RN delivers and bills Medicare Chronic Care Management (CCM), Principal Care Management (PCM), and related care management services; supports Transitional Care Management (TCM) and Annual Wellness Visits (AWVs); closes quality and care gaps; and works to prevent avoidable emergency department visits, hospitalizations, and readmissions. • Delivers Chronic Care Management (CCM), Complex Chronic Care Management, and Principal Care Management (PCM) services in accordance with Medicare requirements, including obtaining and documenting patient consent, developing and maintaining comprehensive electronic care plans, and accurately tracking and documenting time to support billing of CCM/PCM codes (e.g., CPT 99490, 99439, 99487, 99489, 99424–99427).