Role Description 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 - 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