Remote CHF Care Coordinator — Virtual Population Health

Seamless Assist; Houston (TX); Remote; USD 36,000 - 44,000; Full time

Job summary

Cardiac Care Alliance is hiring full-time remote Care Coordinators to support medically complex cardiac patients, especially CHF, through telephonic outreach and CMS-aligned documentation. You will work with RNs and Cardiologists to ensure timely follow-ups, medication reconciliation, and patient education.

Remote role with emphasis on PCM, CCM, and TCM programs, requiring MA certification, at least 2 years in care coordination, and strong communication skills over the phone.

Qualifications

• Active MA certification or equivalent clinical credential and 2 years in care coordination.
• Strong interpersonal communication by phone.
• Familiarity with CMS PCM/CCM/TCM requirements.
• Proficient with care coordination software or EHRs.
• Ability to work independently in a remote environment.

Responsibilities

• Conduct structured telephonic outreach to CHF patients and other complex cardiac patients.
• Maintain a caseload using risk stratification to prioritize care.
• Complete initial assessments and timely follow-ups addressing symptoms, meds, adherence.
• Assess home safety and SDOH barriers; escalate resource needs.
• Advance care planning and specialty follow-up.
• Review dashboards to address care gaps.
• Provide ongoing patient education and self-management strategies for CHF.
• Monitor for worsening conditions and escalate as needed.
• Support transitional care follow-up within 48 hours post-discharge.
• Document time, interventions, care plans in CMS-aligned platform.
• Maintain proactive communication with RNs, Cardiologists, PCPs.

Skills

Care coordination

Ambulatory care

Interpersonal communication

EHR proficiency

Remote work independence

Care coordination software

CMS PCM/CCM/TCM knowledge

Education

MA certification or equivalent

Tools

Care coordination software

Electronic Health Records

Job description

Cardiac Care Alliance is hiring full-time remote Care Coordinators to support medically complex cardiac patients, especially CHF, through telephonic outreach and CMS-aligned documentation. You will work with RNs and Cardiologists to ensure timely follow-ups, medication reconciliation, and patient education.

Remote role with emphasis on PCM, CCM, and TCM programs, requiring MA certification, at least 2 years in care coordination, and strong communication skills over the phone.