Remote Cardiac Care Navigator - CHF Support Lead

Seamless Assist; Baton Rouge (LA); Remote; USD 29,000 - 33,000; Full time

Job summary

Seamless Assist is hiring a Remote Care Navigator for cardiac care coordination. This full-time, non-clinical role focuses on telephonic patient outreach, care plan support, CMS documentation, and coordination with the care team.

Supervising RN will escalate clinical concerns as needed. Responsibilities include risk-based outreach, data entry, medication reconciliation support after discharge, and patient education to improve self-management and reduce hospitalizations.

Qualifications

• Active MA certification or LVN/LPN license is required.
• Minimum 2 years of care coordination, case management, or ambulatory care experience.
• Familiarity with CMS PCM, CCM, and/or TCM program requirements and documentation standards.
• Technologically proficient with care coordination software and/or EHRs.
• AI fluency – uses AI tools to work faster and more efficiently.
• Must be based in and authorized to work in the United States with US business hours.
• Excellent written and verbal English communication; strong phone presence.

Responsibilities

• Conduct structured telephonic outreach to CHF and complex cardiac patients.
• Maintain an assigned patient caseload using risk stratification.
• Complete initial assessments and follow-ups on symptoms, medications, psychosocial status, and SDOH barriers.
• Support CMS follow-ups within 48 hours post-discharge including medication reconciliation and scheduling.
• Provide patient education on CHF self-management and evidence-based strategies.
• Monitor for worsening conditions and escalate to supervising RN as needed.
• Review population health dashboards to address care gaps and wellness metrics.
• Document time, interventions, care plans, and patient goals per CMS standards.

Skills

MA Certification

Care coordination

CMS PCM/CCM/TCM

EHR proficiency

AI fluency

US-based

English communication

Education

MA certification or LVN/LPN license

Tools

Care coordination software

EHR systems

Job description

Seamless Assist is hiring a Remote Care Navigator for cardiac care coordination. This full-time, non-clinical role focuses on telephonic patient outreach, care plan support, CMS documentation, and coordination with the care team.

Supervising RN will escalate clinical concerns as needed. Responsibilities include risk-based outreach, data entry, medication reconciliation support after discharge, and patient education to improve self-management and reduce hospitalizations.