- 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
