Remote Care Coordinator.

About the role

Cardiac Care Alliance (CCA) is a Management Services Organization (MSO) building a high‑performance cardiovascular network that partners with independent cardiologists to deliver value‑based care. CCA is hiring full‑time virtual Care Coordinators to support medically complex patients with cardiac conditions, primarily congestive heart failure (CHF). The role focuses on Principal Care Management (PCM), Chronic Care Management (CCM), and Transitional Care Management (TCM) services via telephonic outreach and technology‑enabled documentation, working with RNs and cardiologists, escalating clinical concerns as needed. This is a non‑clinical, remote position (Dallas/Fort Worth area preferred) requiring a dedicated private workspace for handling PHI and HIPAA compliance.

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
• Address 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

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)

Pay

$26–$32 per hour (based on experience and qualifications)

Schedule

Full‑time, 40 hours per week, Monday‑Friday with flexible business hours; 100% remote work (Dallas/Fort Worth area preferred).