远程护理协调员
Remote Care Coordinator
Cardiac Care Alliance (CCA) 简介
Cardiac Care Alliance 是一家管理服务组织（MSO），致力于打造高性能的心血管网络。我们与独立的心脏病专家合作，提供基于价值的护理（VBC）模式，以补充传统的按服务收费模式。我们的使命是通过主动的护理协调和循证干预，改善患者的可及性、临床结果和整体体验。
职位概述
CCA 正在招聘全职远程护理协调员，以支持患有心脏疾病（主要是心力衰竭）的复杂患者群体。该职位是我们在人群健康计划中的关键角色——通过数据驱动的联络，持续护理和以患者为中心的参与，积极支持高风险患者。
该职位将通过电话联络和基于技术的文档平台，支持主要护理管理（PCM）、慢性病管理（CCM）和过渡期护理管理（TCM）服务。护理协调员将与注册护士和心脏病专家团队协作，在适当的时候上报临床问题和复杂的护理需求。
此职位不需要注册护士执照，但候选人必须具备扎实的临床判断能力、细致的工作态度以及在复杂护理环境中工作的能力。
主要职责
- 对心力衰竭患者和其他复杂心脏疾病患者进行结构化的电话联络
- 管理分配的患者病例，使用风险分层优先安排护理
- 完成初始评估和及时随访，处理当前症状、药物方案和依从性、功能和心理社会状况
- 评估家庭安全性和健康决定因素（SDOH）障碍，包括交通、食物不安全、住房不稳定和照顾者支持；在适当的情况下上报资源需求
- 推进护理计划需求和专科随访
- 查看并处理人群健康仪表板，以解决护理缺口（年度健康检查、缺失的实验室检查、缺乏症状监测等）
- 提供持续的患者教育，推广针对心力衰竭的循证自我管理策略
- 监测病情恶化的迹象或护理缺口，并在需要时上报
- 在出院后 48 小时内支持过渡期护理随访，重点包括药物重整、红色警报症状筛查和预约安排
- 文档记录
查看英文原文
About Cardiac Care Alliance (CCA)
Cardiac Care Alliance is a Management Services Organization (MSO) committed to building a high-performance cardiovascular network. We partner with independent cardiologists to deliver value-based care (VBC) models that complement traditional fee-for-service delivery. Our mission is to improve patient access, clinical outcomes, and overall experience through proactive care coordination and evidence-based interventions.
Position Summary
CCA is hiring full-time virtual Care Coordinators to support a growing population of medically complex patients with cardiac conditions, primarily congestive heart failure (CHF). 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.
This role will focus on supporting Principal Care Management (PCM), Chronic Care Management (CCM), and Transitional Care Management (TCM) services via telephonic outreach and technology-enabled documentation platforms. Care Coordinators work collaboratively with a team of Registered Nurses and Cardiologists, escalating clinical concerns and complex care needs as appropriate.
This position does not require RN licensure, but candidates must have strong clinical acumen, attention to detail, and the ability to navigate complex care environments.
Key Responsibilities
- Conduct structured telephonic outreach to CHF patients and other complex cardiac patients
- Maintain a caseload of assigned patients, using risk stratification to prioritize care
- Complete initial assessments and timely follow-ups addressing current symptoms, medication regimen and adherence, functional and psychosocial status
- Assess home safety and social determinants of health (SDOH) barriers, including transportation, food insecurity, housing instability, and caregiver support; escalate resource needs where appropriate
- Advance care planning needs and specialty care follow-up
- Review and act on population health dashboards to address care gaps (annual wellness visits, missing labs, lack of symptom monitoring, etc.)
- Provide ongoing patient education and promote evidence-based self-management strategies for CHF
- Monitor for signs of worsening conditions or gaps in care, and escalate as needed
- Support transitional care follow-up within 48 hours post-discharge, focusing on 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
- Maintain proactive communication with RNs, Cardiologists, PCP offices, and other clinical partners
Scope of Work – Limitations
This role is non-clinical in license and does not include:
- Clinical assessment or medical diagnosis
- Medication prescribing or adjustments
- Interpretation of diagnostic results (labs, imaging, EKGs, etc.)
- Clinical triage or emergency response
- Home visits or in-person patient contact
- Billing or coding responsibilities beyond required documentation
All clinical decision-making, care plan authorization, and treatment recommendations are made by licensed providers and/or supervising RNs.
Qualifications
Required:
- Active Medical Assistant (MA) certification or equivalent clinical credential (e.g., CNA, EMT, CHW with experience)
- Minimum 2 years of experience in care coordination, case management, or ambulatory care
- Strong interpersonal communication skills and ability to build rapport by phone
- Familiarity with CMS PCM, CCM, and/or TCM program requirements
- Technologically proficient with care coordination software or EHRs
- Ability to work independently and efficiently in a remote environment
Preferred:
- Knowledge of chronic conditions, especially heart failure and associated comorbidities
- Based in or familiar with the Dallas/Fort Worth region
- Bilingual (Spanish/English)
Position Details
- Employment Type: Full-Time, W-2 Contract
- Schedule: 40 hours per week, Monday–Friday (flexible business hours)
- Compensation: $26–$32/hour (based on experience and qualifications)
- 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
Originally posted on Himalayas