- Perform comprehensive clinical assessments via phone
- Develop and update individualized care plans for cardiac patients
- Conduct clinical triage and determine escalation needs
- Lead TCM efforts post-discharge, including medication reconciliation
- Provide patient and caregiver education
- Coordinate with providers and community resources
- Serve as the initial point of contact for escalations and provide clinical oversight to Care Coordinators
- Document all patient encounters in accordance with CMS requirements
- Assess home safety and social determinants of health (SDOH) barriers; escalate resource needs where appropriate
- Maintain proactive communication with Cardiologists, PCP offices, and other clinical partners
- Review and act on population health dashboards to address care gaps (annual wellness visits, missing labs, symptom monitoring, etc.)
- Review reports of CHF symptom worsening
- Triage symptoms such as chest pain or irregular heartbeat
- Assess medication side effects
- Determine need for urgent care or ED visit
- Assist with advanced care planning or palliative care/hospice guidance
- Coordinate urgent appointments with cardiology partners
- Conduct comprehensive assessments and reassessments to identify high-risk patients
- Develop and implement patient-centered, evidence-based care plans
- Perform medication reconciliation and monitor adherence
- Identify and address gaps in care
- Facilitate communication across the care team
- Document clinical findings and interventions per CMS and organizational guidelines
- Participate in interdisciplinary case conferences and quality improvement initiatives
- Prescribing medications (non-APRN role)
- Diagnosing new medical conditions
- Independent billing or claims processing
- In-person patient visits
- Initiating or modifying treatment plans outside of established protocols or without provider input
- Active RN license in Texas or a compact state
- 2+ years of cardiac care or care management experience
- Knowledge of chronic conditions, especially heart failure and associated comorbidities
- Excellent communication and documentation skills
- Based in the Dallas/Fort Worth area
- Experience with EHRs and Remote Patient Monitoring (RPM)
- Bilingual (Spanish/English)
- Employment Type: Full-Time, 1099 Contract
- Schedule: 40 hours per week, Monday–Friday
- Compensation: $45–$60/hour (based on experience)
- 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
Professional Field
Nursing
Other Behavioral, Mental, or Healthcare FieldPatient Focus
Diagnoses
Avoidant Personality Disorder
Issues
Medication Management
Therapeutic Approach
Methodologies
ECT
Pharmacotherapy
Modalities
Individuals
Practice Specifics
Populations
Hospice/Palliative Care
Racial Justice Allied
Settings
Hospice
In-patient Non-Psychiatric
In-patient Psychiatric
Milieu
Non-profit
Private Practice
Research Facilities/Labs/Clinical Trials
Telehealth/Telemedicine
Home Health/In-home





