Remote Cardiac Care Coordinator for CHF & Population Health

seamlessassist; Chicago (IL); Remote; USD 36,000 - 44,000; Full time

Job summary

Cardiac Care Alliance is hiring full-time virtual Care Coordinators to support medically complex CHF patients, focusing on PCM, CCM, and TCM services via telephonic outreach and documentation platforms. Work is 100% remote; strong clinical acumen, attention to detail, and remote-first communication are essential.

Requires MA certification or equivalent, 2+ years in care coordination, and familiarity with CMS PCM/CCM/TCM.

Qualifications

• Active Medical Assistant (MA) certification or equivalent clinical credential (e.g., CNA, EMT, CHW with experience)
• Minimum 2 years of experience in care coordination, case management, or ambulatory care
• Strong interpersonal communication skills and ability to build rapport by phone
• Familiarity with CMS PCM, CCM, and/or TCM program requirements
• Technologically proficient with care coordination software or EHRs
• Ability to work independently and efficiently in a remote environment

Responsibilities

• Conduct structured telephonic outreach to CHF patients and other complex cardiac patients
• Maintain a caseload of assigned patients with risk stratification to prioritize care
• Complete initial assessments and timely follow-ups addressing current symptoms, medication regimen and adherence, functional and psychosocial status
• Assess home safety and SDOH barriers, including transportation, food insecurity, housing instability, and caregiver support; escalate resource needs where appropriate
• Advance care planning needs and specialty care follow-up
• Review and act on population health dashboards to address care gaps (annual wellness visits, missing labs, lack of symptom monitoring, etc.)
• Provide ongoing patient education and promote evidence-based self-management strategies for CHF
• Monitor for signs of worsening conditions or gaps in care, and escalate as needed
• Support transitional care follow-up within 48 hours post-discharge, focusing on medication reconciliation, red-flag symptom screening, and appointment scheduling
• Document time, interventions, care plans, and patient goals in the care management platform in alignment with CMS billing standards
• Maintain proactive communication with RNs, Cardiologists, PCP offices, and other clinical partners

Skills

Medical Assistant certification

Care coordination experience

Interpersonal communication

CMS PCM/CCM/TCM familiarity

EHR/software proficiency

Remote work ability

Job description

Cardiac Care Alliance is hiring full-time virtual Care Coordinators to support medically complex CHF patients, focusing on PCM, CCM, and TCM services via telephonic outreach and documentation platforms. Work is 100% remote; strong clinical acumen, attention to detail, and remote-first communication are essential.

Requires MA certification or equivalent, 2+ years in care coordination, and familiarity with CMS PCM/CCM/TCM.