Remote Cardiac Care Navigator for CHF Management

Seamless Assist; Las Cruces (NM); A distancia; USD 29.000 - 33.000; Jornada completa

Descripción de la vacante

Seamless Assist is hiring a Remote Care Navigator for Cardiac care coordination. The role supports medically complex patients with heart failure through telephonic outreach, care plan support, and CMS-compliant documentation.

Under supervision of RN Care Managers, you will help reduce hospitalizations and promote patient self-management. Requires MA certification or LVN/LPN license and 2+ years in care coordination.

Formación

• Active MA certification or LVN/LPN license.
• Minimum 2 years 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 (US business hours).
• Exceptional written and verbal communication in English.

Responsabilidades

• 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 follow-up within 48 hours post-discharge with medication reconciliation and 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).
• Document time, interventions, care plans, and patient goals per CMS billing standards.
• Maintain proactive communication with RN Care Managers, cardiologists, and PCP offices.

Conocimientos

MA certification

Care coordination experience

CMS PCM CCM TCM knowledge

EHR proficiency

AI fluency

US work authorization

English proficiency

Cardiac knowledge (CHF)

Spanish language (bilingual)

Herramientas

EHRs

Descripción del empleo

Seamless Assist is hiring a Remote Care Navigator for Cardiac care coordination. The role supports medically complex patients with heart failure through telephonic outreach, care plan support, and CMS-compliant documentation.

Under supervision of RN Care Managers, you will help reduce hospitalizations and promote patient self-management. Requires MA certification or LVN/LPN license and 2+ years in care coordination.