Remote Cardiac Care Navigator

Seamless Assist; Houston (TX); Remote; USD 36,000 - 44,000; Full time

Job summary

Cardiac Care Alliance seeks a full-time, 100% remote Care Coordinator to support a population of medically complex cardiac patients, primarily CHF. You will perform telephonic outreach, manage a caseload, and document care plans in the care management platform per CMS standards.

Required are active MA certification or equivalent, 2+ years in care coordination, strong communication, and proficiency with EHRs. Remote role with Dallas/Fort Worth familiarity preferred; HIPAA compliance is essential.

Qualifications

• Active MA certification or equivalent clinical credential.
• Minimum 2 years in care coordination or ambulatory care.
• Strong phone communication and rapport-building skills.
• Familiarity with CMS PCM, CCM, TCM program requirements.
• Proficient with care coordination software or EHRs.
• Ability to work independently in a remote environment.

Responsibilities

• Conduct structured telephonic outreach to CHF and other complex cardiac patients.
• Maintain a caseload and use risk stratification to prioritize care.
• Complete initial assessments and timely follow-ups on symptoms and adherence.
• Assess home safety and SDOH barriers, escalate resource needs as appropriate.
• Advance care planning needs and specialty care follow-up.
• Review population health dashboards and address care gaps.
• Provide patient education and self-management support for CHF.
• Monitor for worsening conditions and escalations as needed.
• Support transitional care follow-up within 48 hours post-discharge.
• Document time, interventions, and care plans in the CMS-aligned platform.
• Maintain proactive communication with RNs, Cardiologists, and PCP offices.

Skills

Care coordination

Interpersonal communication

EHR systems

Remote work

Independent work

Education

Active MA certification or equivalent

Tools

Care coordination software

CMS PCM/CCM/TCM knowledge

Job description

Cardiac Care Alliance seeks a full-time, 100% remote Care Coordinator to support a population of medically complex cardiac patients, primarily CHF. You will perform telephonic outreach, manage a caseload, and document care plans in the care management platform per CMS standards.

Required are active MA certification or equivalent, 2+ years in care coordination, strong communication, and proficiency with EHRs. Remote role with Dallas/Fort Worth familiarity preferred; HIPAA compliance is essential.