Remote CHF Care Coordinator | Population Health

Seamless Assist; Dallas (TX); On-site; USD 36,000 - 44,000; Full time

Job summary

Cardiac Care Alliance (CCA) is seeking full-time virtual Care Coordinators to support medically complex patients with cardiac conditions, primarily CHF, through telephonic outreach and data-enabled documentation. This role partners with RNs and Cardiologists and does not require RN licensure.

Responsibilities include risk stratification, initial assessments, care coordination, home-SDOH assessment, and CMS-compliant documentation. 40-hour weeks, 100% remote; Dallas/Fort Worth region preferred.

Qualifications

• Active Medical Assistant (MA) certification or equivalent clinical credential (e.g., CNA, EMT, CHW with experience).
• Minimum 2 years of experience in care coordination, case management, or ambulatory care.
• Strong interpersonal communication skills and ability to build rapport by phone.
• Familiarity with CMS PCM, CCM, and/or TCM program requirements.
• Technologically proficient with care coordination software or EHRs.
• Ability to work independently and efficiently in a remote environment.

Responsibilities

• Conduct structured telephonic outreach to CHF patients and other complex cardiac patients.
• Maintain a caseload of assigned patients, using risk stratification to prioritize care.
• Complete initial assessments and timely follow-ups addressing current symptoms, medication regimen and adherence, functional and psychosocial status.
• Assess home safety and social determinants of health (SDOH) barriers, including transportation, food insecurity, housing instability, and caregiver support; elevate resource needs where appropriate.
• Advance care planning needs and specialty care follow-up.
• Review and act on population health dashboards to address care gaps (annual wellness visits, missing labs, lack of symptom monitoring, etc.).
• Provide ongoing patient education and promote evidence-based self-management strategies for CHF.
• Monitor for signs of worsening conditions or gaps in care, and elevate as needed.
• Support transitional care follow-up within 48 hours post-discharge, focusing on medication reconciliation, red-flag symptom screening, and appointment scheduling.
• Document time, interventions, care plans, and patient goals in the care management platform in alignment with CMS billing standards.
• Maintain proactive communication with RNs, Cardiologists, PCP offices, and other clinical partners.

Skills

MA certification

Care coordination

CMS PCM/CCM/TCM familiarity

EHRs

Remote work

Tools

Care coordination software

EHRs

Job description

Cardiac Care Alliance (CCA) is seeking full-time virtual Care Coordinators to support medically complex patients with cardiac conditions, primarily CHF, through telephonic outreach and data-enabled documentation. This role partners with RNs and Cardiologists and does not require RN licensure.

Responsibilities include risk stratification, initial assessments, care coordination, home-SDOH assessment, and CMS-compliant documentation. 40-hour weeks, 100% remote; Dallas/Fort Worth region preferred.