Remote Cardiac Care Navigator — Care Coordination Specialist

Seamless Assist; Northern (KY); Hybrid; USD 29,000 - 33,000; Full time

Job summary

Seamless Assist is seeking a Remote Care Navigator – Cardiac to support medically complex CHF patients. This full-time, non-clinical position works under RN supervision, focusing on telephonic outreach, care plan support, CMS documentation, and cross-team coordination.

The ideal candidate holds an active MA credential, has 2+ years in care coordination, is proficient with EHRs, and speaks English well. US work authorization and CST/PST overlap are required.

Qualifications

• Must hold Active MA certification or equivalent credential.
• 2+ years experience in care coordination, case management, or ambulatory care.
• Familiarity with CMS PCM, CCM, and/or TCM program requirements and documentation standards.
• Proficient with care coordination software and EHR systems.
• AI fluency to leverage AI tools for efficiency.
• Based in and authorized to work in the United States, with US business hours overlap.

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 screening, appointment scheduling.
• Provide patient education on CHF self-management and evidence-based strategies.
• Monitor for signs of worsening conditions or care gaps and escalate to supervising RN.
• Review and act on population health dashboards to address care gaps.
• Document time, interventions, care plans, and patient goals per CMS standards.
• Maintain proactive communication with RN Care Managers, cardiologists, and PCP offices.
• Clinical assessment or medical diagnosis
• Medication prescribing or adjustments
• Interpretation of labs, imaging, or EKGs
• Clinical triage or emergency response
• In-person or home visit patient contact
• Billing or coding beyond required time-based documentation

Skills

MA Certification

Care coordination experience

CMS PCM/CCM/TCM

EHR proficient

AI fluency

US work authorization

English communication

Job description

Seamless Assist is seeking a Remote Care Navigator – Cardiac to support medically complex CHF patients. This full-time, non-clinical position works under RN supervision, focusing on telephonic outreach, care plan support, CMS documentation, and cross-team coordination.

The ideal candidate holds an active MA credential, has 2+ years in care coordination, is proficient with EHRs, and speaks English well. US work authorization and CST/PST overlap are required.