Clinical Heart Failure Program Care Coordinator

About the Company

The next generation of independent cardiology is being built here. CardioOne is a physician-led, technology-driven cardiology platform built to empower independent practices to compete, and win, in a rapidly evolving healthcare landscape. Our mission is to provide cardiologists with the tools, infrastructure, and expertise they need to thrive while maintaining full clinical independence. We believe the best care is delivered by physicians who are empowered - not constrained - by the systems around them.

We combine a deep bench of healthcare operators with purpose-built technology and AI-enabled solutions across operations, revenue cycle, imaging, and practice development. From real estate and advanced imaging to clinical workflows and data infrastructure, CardioOne delivers a fully integrated platform designed to drive growth, efficiency, and superior patient outcomes.

Backed by WindRose Health Investors and leading healthcare executives, CardioOne is building one of the most sophisticated and scalable cardiology MSOs in the country - designed to reimagine what is possible for independent cardiology. Cardiovascular Specialists of New England (CSNE)

is on a mission to redefine heart health and shift the paradigm, improving and elevating the lives of patients with cardiovascular conditions in New Hampshire. We use our advanced skills and technology to assess, diagnose, and treat general and complex cardiovascular conditions, including heart failure, heart valve disease, arrhythmia, and coronary artery disease.

About the Job At our rapidly growing practice, Cardiovascular Specialists of New England, we are seeking a highly motivated Heart Failure Program Care Coordinator. You will be responsible for coordinating and supporting the ongoing care of patients enrolled in the practice’s Heart Failure Program. This role serves as a central point of coordination between patients, families, cardiologists, advanced practice providers, clinical staff, hospitals, and other healthcare partners. The Care Coordinator supports proactive management of patients with heart failure through timely follow-up, medication reconciliation, patient education, monitoring of symptoms and vital signs, coordination of diagnostic testing and appointments, and identification and escalation of clinical concerns. The position is focused on improving patient outcomes, promoting adherence to evidence-based treatment plans, reducing avoidable hospitalizations and readmissions, and ensuring continuity of care across the healthcare continuum. You will report directly to the Clinical Nurse Manager, Lisa Goupil. What you’ll do:

Heart Failure Care Coordination Coordinate the care of patients enrolled in the Heart Failure Program from hospital discharge through ongoing outpatient management to optimize patient outcomes

Review hospital discharge summaries, emergency department records, cardiology notes, diagnostic results, medication changes, and treatment plans for patients with heart failure.

Identify patients requiring timely post-discharge follow-up and ensure appointments are scheduled within the timeframe established by the clinical team.

Coordinate follow-up visits with cardiologists, APPs, primary care providers, and other specialists as appropriate, to best support patient experience and coordination of care across the continuum.

Coordinate required diagnostic testing, including echocardiograms, laboratory testing, imaging, and other heart failure-related studies to ensure care is delivered in a well-coordinated, efficient and cost effective manner.

Track patients with recent heart failure admissions, emergency department visits, worsening symptoms, or other indicators of increased clinical risk.

Maintain awareness of patients' care plans and ensure appropriate follow-through on provider recommendations and orders.

Patient Monitoring & Early Identification of Clinical Changes Conduct scheduled telephone and electronic outreach to heart failure patients according to established program protocols.

Assess and document patient-reported symptoms and changes in clinical status, including weight changes, edema, shortness of breath, fatigue, dizziness, blood pressure, heart rate, and other relevant indicators.

Support remote patient monitoring activities, including review and communication of weight, blood pressure, heart rate, and other patient-generated health data as directed by the clinical team.

Identify changes that may indicate worsening heart failure and promptly escalate concerns to the appropriate nurse, APP, or physician.

Follow established escalation protocols for abnormal symptoms, vital signs, weight changes, medication concerns, or other clinical findings.

Assist with coordination of urgent evaluation when directed by the clinical team.

Medication Management and Adherence Support Perform medication reconciliation following hospitalizations, emergency department visits, and other clinically significant encounters.

Verify that medication changes documented in discharge instructions and provider orders have been appropriately communicated to the patient.

Reinforce prescribed medication regimens and assist patients in identifying barriers to medication adherence.

Identify issues related to medication access, affordability, pharmacy coordination, side effects, or patient understanding and escalate as appropriate.

Support adherence to heart failure treatment plans without independently initiating, discontinuing, or modifying medications unless specifically authorized by the clinical team and within established protocols.

Patient Education and Self Management Support Provide education and reinforcement regarding heart failure self-management, including:

Daily weight monitoring

Recognition of worsening symptoms

Medication adherence

Dietary and sodium recommendations as directed by the clinical team

Fluid management recommendations as prescribed

Blood pressure and heart rate monitoring

When and how to contact the practice

When emergency evaluation may be necessary

Reinforce individualized education provided by physicians, APPs, nurses, dietitians, pharmacists, and other members of the Heart Failure Program.

Help patients and families understand their treatment plan and identify barriers to successful self-management.

Encourage patients to actively participate in their care and recognize early changes in their condition.

Transitional Care & Hospital Readmission Reduction Participate in post-hospital transition-of-care activities for patients admitted with heart failure.

Contact patients within the program's defined post-discharge timeframe to assess recovery, reconcile medications, review discharge instructions, and identify barriers to care.

Ensure appropriate follow-up appointments and testing are scheduled following hospitalization.

Communicate relevant clinical information to the treating cardiologist, APP, nurse, or other members of the care team.

Track patients following heart failure-related hospitalizations and identify opportunities for intervention to reduce avoidable readmissions.

Care Team Coordination Serve as a primary coordination resource for patients enrolled in the Heart Failure Program.

Collaborate closely with cardiologists, APPs, nurses, Medical Assistants, clinical care coordinators, and other practice staff.

Communicate significant patient concerns, abnormal findings, care barriers, and changes in clinical status promptly to the appropriate clinical team member.

Coordinate with hospitals, primary care providers, skilled nursing facilities, home health agencies, rehabilitation programs, pharmacies, and other external healthcare organizations to optimize transitions of care

Participate in interdisciplinary meetings, case reviews, team huddles, and Heart Failure Program initiatives.

Documentation & Program Tracking Document all patient contacts, assessments, education, interventions, communications, and follow-up activities accurately in the EMR.

Maintain accurate program enrollment and patient tracking information.

Track completion of follow-up appointments, diagnostic testing, laboratory monitoring, and other elements of the patient's care plan.

Maintain appropriate documentation to support care coordination, quality initiatives, and applicable billing or reporting requirements.

Protect patient confidentiality and comply with HIPAA and all applicable organizational, state, and federal requirements.

Quality Improvement & Program Development Support Heart Failure Program initiatives designed to improve patient outcomes, patient engagement, access, and continuity of care.

Participate in quality improvement activities related to hospitalizations, readmissions, medication adherence, patient engagement, and care-plan compliance.

Identify recurring barriers, workflow issues, or opportunities for improvement and communicate recommendations to program leadership.

Assist with development and implementation of standardized Heart Failure Program workflows, protocols, patient education materials, and tracking processes.

Support collection and monitoring of program metrics as assigned.

What you’ll need:

Certified Medical Assistant or Licensed Practical Nurse preferred.

Current BLS certification required.

Additional cardiac or heart failure education/certification preferred

Minimum of 2 years of clinical cardiology experience preferred.

Experience with heart failure patients strongly preferred.

Experience with transitional care management, chronic disease management, remote patient monitoring, or care coordination preferred.

Experience working in an outpatient cardiology or specialty practice preferred.

Skills & Competencies

Working knowledge of cardiovascular disease, particularly heart failure, common cardiac diagnoses, medications, and treatment plans.

Ability to recognize and appropriately escalate changes in patient-reported symptoms and clinical data.

Strong communication and patient-interaction skills.

Ability to interpret clinical documentation and cardiac terminology.

Strong organizational skills with exceptional attention to detail.

Ability to manage multiple patients and follow-up activities while meeting established timelines.

Proficiency with EMR systems and care-management or remote-monitoring platforms.

Ability to work collaboratively within a multidisciplinary clinical team.

Strong telephone communication and patient education skills.

Compassionate, patient-centered approach.

Ability to maintain appropriate professional boundaries and recognize when clinical concerns require escalation to a licensed clinical professional.

Additional Information This role will include a matching 401K, 12 days Paid Time Off, and 8 Paid Federal Holidays. Outpatient cardiology environment with regular telephone, electronic, EMR-based, and in-person patient interactions. The position requires frequent communication with patients, families, providers, hospitals, and external healthcare organizations.

Work Location You will work out of the Londonderry, NH office as well as the Manchester, NH office (when needed).