Remote Cardiac Care Navigator – CHF & Care Coordination

Seamless Assist; Atlanta (GA); Remote; USD 29,000 - 33,000; Full time

Job summary

Seamless Assist in the United States is hiring a Remote Care Navigator for Cardiac care to support medically complex patients with congestive heart failure (CHF). This full-time, non-clinical role focuses on telephonic outreach, care plan support, CMS-compliant documentation, and coordination with the care team under RN supervision.

The position emphasizes structured outreach, documentation, EHR use, and population health dashboards.

Qualifications

• Active MA certification or LVN/LPN license (required).
• Minimum 2 years of experience 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 with US business hours (CST/PST overlap).
• Exceptional written and verbal communication in English; strong phone presence.

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 escalate 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.
• Clinical assessment or medical diagnosis (note: role does not perform independent prescribing).
• Billing or coding beyond required time-based documentation.

Skills

Care coordination

EHR proficiency

AI fluency

Communication skills

Education

Active Medical Assistant certification or LVN/LPN license

Tools

EHR platforms

Care management software

Population health dashboards

Job description

Seamless Assist in the United States is hiring a Remote Care Navigator for Cardiac care to support medically complex patients with congestive heart failure (CHF). This full-time, non-clinical role focuses on telephonic outreach, care plan support, CMS-compliant documentation, and coordination with the care team under RN supervision.

The position emphasizes structured outreach, documentation, EHR use, and population health dashboards.