Remote Care Coordinator

Advance care planning needs and specialty care follow-upReview 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 CHFMonitor 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.