RN Care Manager – Cardiac

Seamlessassist•Texas City, TX

13d•Remote

About The Position

Cardiac Care Alliance (CCA) is a Management Services Organization (MSO) dedicated to building a high-performance cardiovascular network. We work in close partnership with independent cardiologists to complement fee-for-service care with value-based care (VBC) models. Our mission is to improve patient access, outcomes, and experiences by delivering proactive, patient-centered care across the cardiac continuum. CCA is seeking experienced Registered Nurse (RN) Care Managers to support a high-acuity population of patients with complex cardiac conditions, including congestive heart failure (CHF) and other comorbidities. This is a full-time, remote, hourly contract position focused on delivering advanced clinical support through clinical triage, care plan development, and high-risk care management, including Transitional Care Management (TCM), Principal Care Management (PCM), Complex Care Management (CCM), Remote Patient Monitoring (RPM), and other applicable clinical programs. 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. You'll help reduce avoidable hospitalizations, support patient self-management, and contribute to better long-term cardiac outcomes. This position also serves as the clinical escalation point for non-RN Care Coordinators, supporting continuity and collaboration across the care team.

Requirements

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
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

Nice To Haves

Based in the Dallas/Fort Worth area
Experience with EHRs and Remote Patient Monitoring (RPM)
Bilingual (Spanish/English)

Responsibilities

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