Remote Care Navigator

Role Overview

Our client — a cardiac care Aliance 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
* Bilingual — Spanish/English (not a must)