Remote Care Coordinator
C
Cardiac Care AllianceCardiac care
United StatesContractJunior
Salary26 - 32 USD per hour
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Job Details
- Languages
- Bilingual (Spanish/English) preferred
- Experience
- Minimum 2 years of experience in care coordination, case management, or ambulatory care
- Required Skills
- EHR
Requirements
- Hold an active Medical Assistant (MA) certification or equivalent clinical credential, such as CNA, EMT, or CHW with experience.
- Have a minimum of 2 years of experience in care coordination, case management, or ambulatory care.
- Be familiar with CMS PCM, CCM, and/or TCM program requirements.
- Be technologically proficient with care coordination software or EHRs.
- Be able to work independently and efficiently in a remote environment.
- Have a dedicated, private workspace suitable for handling PHI and a secure internet connection.
- Comply with HIPAA and patient privacy policies.
- Knowledge of chronic conditions, especially heart failure and associated comorbidities, is preferred.
- Familiarity with the Dallas/Fort Worth region is preferred.
- Bilingual Spanish/English ability is preferred.
Responsibilities
- Conduct structured telephonic outreach to patients with CHF and other complex cardiac conditions.
- Maintain an assigned patient caseload and use risk stratification to prioritize care.
- Complete initial assessments and timely follow-ups covering symptoms, medication regimen and adherence, functional status, and psychosocial status.
- Assess home safety and social determinants of health barriers, and escalate resource needs when appropriate.
- Review population health dashboards and address care gaps, including missing labs and lack of symptom monitoring.
- Educate patients and promote evidence-based self-management strategies for CHF.
- Monitor for worsening conditions or gaps in care and escalate concerns as needed.
- Support transitional care follow-up within 48 hours after discharge, including medication reconciliation, red-flag symptom screening, and appointment scheduling.
- Document time, interventions, care plans, and patient goals in the care management platform in alignment with CMS billing standards.
- Communicate proactively with RNs, cardiologists, PCP offices, and other clinical partners.
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