13
Total Enrolled
7
CCM Active
2
RPM Active
2
TCM Active
$0
Monthly Est.
2
PCM Active
0
BHI Active
Chronic Care Management
7 patients
Monthly time-based billing for patients with 2+ chronic conditions. Min 20 min/month for billing.
View Tracker →Remote Patient Monitoring
2 devices
Device-based daily readings. Requires 16+ days of transmitted data per month for billing.
View Monitor →Transitional Care
2 episodes
Post-discharge follow-up. Phone within 2 days, face-to-face within 7–14 days.
View Workflow →Principal Care Management
2 patients
Single high-risk condition management. Min 30 min/month. Mutually exclusive with CCM.
View Tracker →Behavioral Health
0 patients
General BHI (20 min) or CoCM (36 min). Psychiatric integration and care management.
View Tracker →Plan Today's Visit
See every billable opportunity at a facility — CCM, RPM, BHI, AWV, Dementia, ACP, HCC — in one matrix.
Scan Census Sheet
Photograph an annotated worksheet to batch-update enrollments, consent, AWV, and insurance records.
Submit Daily Worksheet
Upload completed MA worksheets (.docx) to auto-import CCM, RPM, TCM, AWV, Enrollment, or BHI data.
Recent Activity
Doe, Jane — Care plan review, medication reconciliation
Doe, Jane — Phone call with pharmacy, refill coordination
Doe, Jane — Reviewed lab results, updated care plan
Smith, Robert — Coordinated specialist appointment
Smith, Robert — Follow-up call, symptom check
Johnson, Mary — Comprehensive medication review
Johnson, Mary — Coordinated home health services
Johnson, Mary — Care plan update, family conference call
Williams, David — Brief phone check, reviewed vitals
Abdulmajid, A. — Nursing facility care coordination
Upcoming Deadlines
Jordan, Paul
Overdue
Martinez, Elena
Overdue
Foster, Lilian
6d left
Garcia, Maria
6d left