Remote Cardiac Care Navigator – Care Coordination Pro

Seamlessassist; Oklahoma; Remote; USD 43,000 - 50,000; Full time

Job summary

Seamlessassist is seeking a REMOTE CARE NAVIGATOR for CARDIAC to support medically complex cardiac patients, focusing on telephonic outreach, care plan support, CMS documentation, and collaboration with RN Care Managers.

You will handle risk-based caseloads, provide CHF self-management education, document interventions per CMS billing standards, and escalate clinical concerns to the supervising RN. Strong English communication and US work authorization are required.

Qualifications

• Active MA certification or equivalent credential.
• Minimum 2 years in care coordination, case management, or ambulatory care.
• Familiarity with CMS PCM, CCM, and/or TCM program requirements and documentation standards.
• Technologically proficient with care coordination software and/or EHRs.
• AI fluency — actively uses AI tools to work faster and more efficiently.
• Must be based in and authorized to work in the United States — time zone compatibility required (US business hours, CST/PST overlap).
• Exceptional written and verbal communication in English; strong phone presence assessed at screening.

Responsibilities

• Conduct structured telephonic outreach to CHF and complex cardiac patients.
• Maintain an assigned patient caseload using risk stratification to prioritize outreach.
• Complete initial assessments and follow-ups covering symptoms, medications, psychosocial status, and SDOH barriers.
• Support Transitional Care Management (TCM) follow-up within 48 hours post-discharge — medication reconciliation, red-flag symptom screening, appointment scheduling.
• Provide patient education on CHF self-management and evidence-based strategies.
• Monitor for signs of worsening conditions or care gaps and escalated to supervising RN.
• Review and act on population health dashboards to address care gaps (wellness visits, labs, symptom monitoring).
• Document time, interventions, care plans, and patient goals per CMS billing standards.
• Maintain proactive communication with RN Care Managers, cardiologists, and PCP offices.

Skills

Care coordination experience

CMS documentation knowledge

EHR proficiency

AI fluency

US work authorization

Excellent English communication

Telephonic outreach

Education

Active Medical Assistant certification or equivalent credential

Tools

EHR platforms

Care management software

Population health dashboards

CMS documentation tools

Job description

Seamlessassist is seeking a REMOTE CARE NAVIGATOR for CARDIAC to support medically complex cardiac patients, focusing on telephonic outreach, care plan support, CMS documentation, and collaboration with RN Care Managers.

You will handle risk-based caseloads, provide CHF self-management education, document interventions per CMS billing standards, and escalate clinical concerns to the supervising RN. Strong English communication and US work authorization are required.