100% Remote — US only (Dallas/Fort Worth area preferred)
Tools
EHR platforms, care management software, population health dashboards, CMS documentation tools
Role Overview
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 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 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
