Remote Cardiac Care Navigator (CHF Support)

Seamlessassist; Denver (CO); Remote; USD 29,000 - 33,000; Full time

Job summary

Seamlessassist is seeking a Remote Care Navigator for Cardiac care to support medically complex patients with heart failure. This full-time, remote role focuses on telephonic outreach, care plan support, CMS documentation, and coordination with the care team.

Under supervision of RN Care Managers, you will manage patient outreach, update care plans, and ensure timely follow-up within CMS guidelines. This non-clinical role emphasizes patient education, data entry, and cross-functional

Qualifications

• Active MA certification or equivalent clinical credential.
• Minimum 2 years of care coordination, case management, or ambulatory care.
• Familiarity with CMS PCM, CCM, and/or TCM program requirements.
• 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.
• 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 elevate 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.
• 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

CMS PCM/CCM/TCM familiarity

EHR proficiency

AI fluency

US work authorization

English communication

Education

Equivalent clinical credential (CNA/EMT/CHW)

Tools

EHR systems

CMS documentation tools

Population health dashboards

Job description

Seamlessassist is seeking a Remote Care Navigator for Cardiac care to support medically complex patients with heart failure. This full-time, remote role focuses on telephonic outreach, care plan support, CMS documentation, and coordination with the care team.

Under supervision of RN Care Managers, you will manage patient outreach, update care plans, and ensure timely follow-up within CMS guidelines. This non-clinical role emphasizes patient education, data entry, and cross-functional