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Responsible for assisting patients in achieving health outcomes, as well as the other determinants that influence these outcomes and the interventions that impact the patient’s health, with the ultimate goal of achieving the “triple aim” of healthcare —better health, better care, and lower costs. Focus on high-risk individuals, ensuring ordered testing is completed, appointments are scheduled according to HEDIS and disease-management measures, and that health expectations are met. These health expectations are set by the patient, provider and the insurer. At the same time, monitoring and addressing comprehensive prevention and chronic care needs of every patient. The goal is to keep all individuals as healthy as possible, minimizing expensive intervention, and maximizing insurance incentives.