远程护理协调员.
Remote Care Coordinator.
关于心脏病保健联盟 (CCA) 心脏病保健同盟是一个致力于建立高性能心血管网络的管理服务组织 (MSO).我们与独立的心脏学家合作，提供基于价值的护理模型 (VBC),以补充传统费用为服务。我们的使命是通过积极的护理协调和基于证据的干预来改善患者访问量，临床结果和整体经验。职位总结 CCA 正在聘请全日制虚拟护理协调员支持患有医疗复杂的心脏疾病，主要是重症心衰竭 (CHF) 的不断增长的人口。通过电话传播和技术支持的文档平台，这项角色将重点关注主要护理管理 (PCM),慢性护理管理，并通过过渡护理管理服务。护理协调员与注册护士和心脏病学家团队合作，根据需要加剧临床问题和复杂护理需求。申请人必须具有强大的临床敏，注意细节和能够导航复杂的护理环境。关键责任 · 对 CHF 患者和其他复杂的心脏病患者进行结构化的电话沟通 ·使用风险分层来优先考虑护理，保持分配患者的案件负载 ·完成初步评估和及时跟踪，以解决当前症状，药物方案和遵守情况，功能性和心理社会状况 ·评估家庭安全和健康障碍 (SDOH) 的社会决定因素，包括交通运输，粮食不安全，住房不稳定性以及照顾者支持；根据需要，加强资源需求 ·提前计划护理和专业护理的后续行动 ·审查和采取行动对人口健康仪表来解决护理缺陷 （年次健身访问，缺乏实验室，缺乏症状监测等）·提供持续的患者教育并促进基于证据的 CHF 自治策略 ·监控病情恶化或医疗缺陷的迹象以及必要时升级 ·支持退院后48小时内过渡护理的随访，重点关注药物调整，红旗症状查和约会安排 · Doc
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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