Remote Care Navigator

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

Job summary

SeamlessAssist is hiring a Remote Care Navigator for Cardiac care to support medically complex CHF patients through phone outreach, care plan support, and CMS-compliant documentation.

The role works under RNs and focuses on non-clinical coordination, reducing hospitalizations, and promoting patient self-management in a fully remote US-based team.

Qualifications

• Active MA certification or equivalent clinical credential (CNA, EMT, CHW with relevant experience)
• 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 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
• 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

Tools

EHR systems

Care coordination software

Job description

REMOTE CARE NAVIGATOR – CARDIAC

Sector

Healthcare — Cardiac Care Coordination

Reports To

RN Care Manager / Clinical Supervisor

Type

Full-Time · 40 hours/week

Schedule

Monday–Friday · Weekends -Flexible business hours (US hours, CST/PST overlap required)

Rate

$21–$24 USD/hour (based on experience)

Contract

W-2

Location

100% Remote — US only (Dallas/Fort Worth area preferred)

Tools

EHR platforms, care management software, population health dashboards, CMS documentation tools

Role Overview

Our client — a cardiac care management MSO — is hiring full-time virtual Care Navigators to support a growing population of medically complex patients with cardiac conditions, primarily congestive heart failure (CHF). This is a non-clinical (non-licensed) role focused on telephonic patient outreach, care plan support, CMS-compliant documentation, and coordination across the care team. The Care Navigator works under the supervision of RN Care Managers, escalating all clinical concerns appropriately. This role plays a critical part in reducing avoidable hospitalizations and supporting patient self-management over the long term.

Key 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 escalate 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

Scope Limitations — This Role Does NOT Include

• 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
  Experience & Skills

  Required:

  • Active Medical Assistant (MA) certification or equivalent clinical credential (CNA, EMT, CHW with relevant experience)
  • 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

  Preferred:

  • Knowledge of cardiac conditions — especially heart failure and associated comorbidities
  • Bilingual — Spanish/English (not a must)