Remote Care Navigator – Cardiac

Role Overview

Our client, a cardiac care management Management Services Organization (MSO), is seeking full-time virtual Care Navigators to support a growing population of medically complex patients, primarily those with congestive heart failure (CHF). This is a non-clinical, non-licensed position focused on telephonic patient outreach, care plan support, CMS-compliant documentation, and coordination across the care team. The Care Navigator operates under the supervision of RN Care Managers, ensuring all clinical concerns are escalated appropriately. This role is critical for reducing avoidable hospitalizations and supporting long-term patient self-management.

Key Responsibilities

• Conduct structured telephonic outreach to patients with CHF and complex cardiac conditions.

• Manage an assigned patient caseload, utilizing risk stratification to prioritize outreach efforts.

• Perform initial assessments and follow-ups covering symptoms, medication adherence, psychosocial status, and Social Determinants of Health (SDOH) barriers.

• Support Transitional Care Management (TCM) follow-ups within 48 hours of hospital discharge, including medication reconciliation, red-flag symptom screening, and appointment scheduling.

• Provide patient education on CHF self-management and evidence-based care strategies.

• Monitor for signs of worsening conditions or care gaps, elevating issues to the supervising RN as needed.

• Review and act on population health dashboards to address care gaps such as wellness visits, lab work, and symptom monitoring.

• Document time, interventions, care plans, and patient goals in accordance with CMS billing standards.

• Maintain proactive communication with RN Care Managers, cardiologists, and Primary Care Provider (PCP) offices.

Scope Limitations

This role does not include the following clinical or administrative duties:

• 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 Qualifications

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

• Minimum of 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 Electronic Health Records (EHRs).

• AI fluency: actively uses AI tools to enhance work speed and efficiency.

• Must be based in and authorized to work in the United States with time zone compatibility (US business hours, CST/PST overlap required).

• Exceptional written and verbal communication skills in English; strong phone presence assessed during screening.

Preferred Qualifications

• Knowledge of cardiac conditions, particularly heart failure and associated comorbidities.

• Bilingual proficiency in Spanish/English (preferred but not mandatory).

Job Details

• Sector: Healthcare — Cardiac Care Coordination

• Reports To: RN Care Manager / Clinical Supervisor

• Type: Full-Time · 40 hours/week

• Schedule: Monday–Friday. Flexible business hours required with overlap into CST/PST time zones.

• 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