Remote Cardiac Care Navigator - CHF & Care Coordination

Seamlessassist; San Antonio (TX); Remote; USD 29,000 - 33,000; Full time

Job summary

Seamlessassist in the United States is seeking a Remote Care Navigator - Cardiac to support medically complex patients with CHF. This full-time, 40-hour/week role is non-clinical, telephonic outreach, care plan support, CMS-compliant documentation, and cross-functional coordination under RN supervision.

You will have active MA certification or LVN/LPN license, 2+ years in care coordination, familiarity with CMS PCM/CCM/TCM, and proficiency with EHRs; AI tools use is expected.

Qualifications

• Active Medical Assistant (MA) certification or LVN/LPN license.
• 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 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.
• 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 billing standards.
• Maintain proactive communication with RN Care Managers, cardiologists, and PCP offices.

Skills

MA certification or LVN/LPN license

2+ years care coordination

CMS PCM/CCM/TCM knowledge

EHR proficiency

AI fluency

US work authorized

English communication

Education

MA certification or LVN/LPN

Tools

EHR platforms

care management software

population health dashboards

CMS documentation tools

Job description

Seamlessassist in the United States is seeking a Remote Care Navigator - Cardiac to support medically complex patients with CHF. This full-time, 40-hour/week role is non-clinical, telephonic outreach, care plan support, CMS-compliant documentation, and cross-functional coordination under RN supervision.

You will have active MA certification or LVN/LPN license, 2+ years in care coordination, familiarity with CMS PCM/CCM/TCM, and proficiency with EHRs; AI tools use is expected.