Remote Cardiac Care Navigator - CHF Support

seamlessassist; Texas City (TX); Remote; USD 29,000 - 33,000; Full time

Job summary

SeamlessAssist is hiring full-time remote Care Navigators to support medically complex cardiac patients, mainly CHF. This non-clinical role focuses on telephonic outreach, care plan support, CMS documentation, and care coordination under RN supervision.

The role emphasizes reducing avoidable hospitalizations, aiding patient self-management, and collaboration with cardiology and primary care teams. Must work US hours with CST/PST overlap.

Qualifications

• Active Medical Assistant certification or equivalent credential.
• 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—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.

Skills

MA Certification

Care Coordination

CMS PCM/CCM/TCM

EHR Proficiency

AI Fluency

US Work Authorized

English Communication

Education

Active MA Credential

Tools

EHR Systems

Care Management Software

Job description

SeamlessAssist is hiring full-time remote Care Navigators to support medically complex cardiac patients, mainly CHF. This non-clinical role focuses on telephonic outreach, care plan support, CMS documentation, and care coordination under RN supervision.

The role emphasizes reducing avoidable hospitalizations, aiding patient self-management, and collaboration with cardiology and primary care teams. Must work US hours with CST/PST overlap.