RN Care Manager Cardiac

Cardiac Care Alliance (CCA)

Cardiac Care Alliance is a Management Services Organization (MSO) dedicated to building a high-performance cardiovascular network. We work in close partnership with independent cardiologists to complement fee-for-service care with value-based care (VBC) models. Our mission is to improve patient access, outcomes, and experiences by delivering proactive, patient-centered care across the cardiac continuum.

Position Summary

CCA is seeking experienced Registered Nurse (RN) Care Managers to support a high-acuity population of patients with complex cardiac conditions, including congestive heart failure (CHF) and other comorbidities. This is a full-time, remote, hourly contract position focused on delivering advanced clinical support through clinical triage, care plan development, and high-risk care management, including Transitional Care Management (TCM), Principal Care Management (PCM), Complex Care Management (CCM), Remote Patient Monitoring (RPM), and other applicable clinical programs.

This role is integral to our population health initiatives proactively supporting at-risk patients with data-informed outreach, continuity of care, and patient-centered engagement. You'll help reduce avoidable hospitalizations, support patient self-management, and contribute to better long-term cardiac outcomes.

This position also serves as the clinical escalation point for non-RN Care Coordinators, supporting continuity and collaboration across the care team.

Key Responsibilities

• Perform comprehensive clinical assessments via phone
• Develop and update individualized care plans for cardiac patients
• Conduct clinical triage and determine escalation needs
• Lead TCM efforts post-discharge, including medication reconciliation
• Provide patient and caregiver education
• Coordinate with providers and community resources
• Serve as the initial point of contact for escalations and provide clinical oversight to Care Coordinators
• Document all patient encounters in accordance with CMS requirements
• Assess home safety and social determinants of health (SDOH) barriers; escalate resource needs where appropriate
• Maintain proactive communication with Cardiologists, PCP offices, and other clinical partners
• Review and act on population health dashboards to address care gaps (annual wellness visits, missing labs, symptom monitoring, etc.)

Clinical Escalation Responsibilities

• Review reports of CHF symptom worsening
• Triage symptoms such as chest pain or irregular heartbeat
• Assess medication side effects
• Determine need for urgent care or ED visit
• Assist with advanced care planning or palliative care/hospice guidance
• Coordinate urgent appointments with cardiology partners

Scope of Practice and Limitations

This role includes clinical assessment, nursing triage, patient education, and care coordination in line with industry standards for RN-led care management. RN Care Managers are expected to:

• Conduct comprehensive assessments and reassessments to identify high-risk patients
• Develop and implement patient-centered, evidence-based care plans
• Perform medication reconciliation and monitor adherence
• Identify and address gaps in care
• Facilitate communication across the care team
• Document clinical findings and interventions per CMS and organizational guidelines
• Participate in interdisciplinary case conferences and quality improvement initiatives

This role does NOT include:

• Prescribing medications (non-APRN role)
• Diagnosing new medical conditions
• Independent billing or claims processing
• In-person patient visits
• Initiating or modifying treatment plans outside of established protocols or without provider input

Qualifications

Required:

• Active RN license in Texas or a compact state
• 2+ years of cardiac care or care management experience
• Knowledge of chronic conditions, especially heart failure and associated comorbidities
• Excellent communication and documentation skills

Preferred:

• Based in the Dallas/Fort Worth area
• Experience with EHRs and Remote Patient Monitoring (RPM)
• Bilingual (Spanish/English)

Position Details

• Employment Type: Full-Time, 1099 Contract
• Schedule: 40 hours per week, MondayFriday
• Compensation: $45$60/hour (based on experience)
• Work Environment: 100% Remote (Dallas/Fort Worth area preferred)
• Potential for ongoing engagement or full-time employment for the right candidate
• Must have a dedicated, private workspace suitable for handling PHI, a secure internet connection, and comply with HIPAA and patient privacy policies at all times