Remote Care Coordinator – Cardiac

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…