Remote Care Navigator

Remote Care Navigator Cardiac

Our client a cardiac care management MSO is hiring full-time virtual Care Navigators to support a growing population of medically complex patients with cardiac conditions, primarily congestive heart failure (CHF). This is a non-clinical (non-licensed) role focused on telephonic patient outreach, care plan support, CMS-compliant documentation, and coordination across the care team. The Care Navigator works under the supervision of RN Care Managers, escalating all clinical concerns appropriately. This role plays a critical part in reducing avoidable hospitalizations and supporting patient self-management over the long term.

Key Responsibilities

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

Scope Limitations This Role Does NOT Include

• 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:

• Active Medical Assistant (MA) certification or equivalent clinical credential (CNA, EMT, CHW with relevant experience)
• Minimum 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 EHRs
• AI fluency actively uses AI tools to work faster and more efficiently.
• Must be based in and authorized to work in the United States time zone compatibility required (US business hours, CST/PST overlap)
• Exceptional written and verbal communication in English; strong phone presence assessed at screening

Preferred:

• Knowledge of cardiac conditions especially heart failure and associated comorbidities
• Bilingual Spanish/English (not a must)