Remote CHF Care Navigator for Cardiac Care

Seamless Assist; San Antonio (TX); Remote; USD 29,000 - 33,000; Full time

Job summary

Seamless Assist is seeking a Remote Care Navigator to support cardiac care coordination for medically complex patients, primarily CHF. This non-clinical role involves telephonic outreach, care plan support, CMS-compliant documentation, and coordination with the care team under RN supervision.

The position is 100% remote in the US with US-hours overlap (CST/PST). Requires MA/LVN/LPN, 2+ years in care coordination, CMS knowledge, and English proficiency; AI tools usage is encouraged.

Qualifications

• 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.
• Technologically proficient with care coordination software and/or EHRs.
• AI fluency and use of AI tools to improve efficiency.
• Must be based in the United States with CST/PST overlap.
• Excellent English written and verbal communication.

Responsibilities

• Conduct structured telephonic outreach to CHF and complex cardiac patients.
• Maintain assigned patient caseload using risk stratification to prioritize outreach.
• Complete initial assessments and follow-ups covering symptoms, meds, psychosocial status, and SDOH barriers.
• Support TCM follow-up within 48 hours post-discharge - reconciliation, red-flag screening, scheduling.
• Provide patient education on CHF self-management and evidence-based strategies.
• Monitor for worsening signs and escalate to supervising RN.
• Review dashboards to address care gaps (wellness visits, labs, monitoring).
• Document time, interventions, care plans, and patient goals per CMS standards.
• Coordinate with RN Care Managers, cardiologists, and PCP offices.

Skills

MA certification / LVN-LPN license

Care coordination experience

CMS PCM/CCM/TCM knowledge

EHR/care coordination software

AI fluency

US work authorization

English communication

Spanish/English (optional)

Cardiac knowledge (HF)

Tools

EHR systems

Care coordination software

Job description

Seamless Assist is seeking a Remote Care Navigator to support cardiac care coordination for medically complex patients, primarily CHF. This non-clinical role involves telephonic outreach, care plan support, CMS-compliant documentation, and coordination with the care team under RN supervision.

The position is 100% remote in the US with US-hours overlap (CST/PST). Requires MA/LVN/LPN, 2+ years in care coordination, CMS knowledge, and English proficiency; AI tools usage is encouraged.