Provides coordinated case management services to eligible patients with diabetes and hypertension. Will assess, monitor, and evaluate services and options required to meet an individual's health needs throughout various transitions of care. Provide support for patient self management of disease and behavior modification interventions. Able to apply motivational interviewing techniques to develop patient centered goals of care. Act as a patient advocate while coordinating continuity of patient care with patients and families following hospital admission, discharge, and emergency department visits.