Care Coordinator; RN Cardiology Telehealth

The RN Care Coordinator provides telehealth-based care coordination and chronic disease management for patients served by the cardiology clinic. The role supports Principal Care Management (PCM), remote care management, patient education, care transitions, and collaboration across the patient’s care team to improve outcomes and continuity of care.

• Conduct telehealth outreach, assessments, and follow-up for patients with chronic cardiovascular conditions, including heart failure, coronary artery disease, hypertension, arrhythmias, and cardiomyopathy.
• Coordinate Principal Care Management (PCM) and remote care-management services for eligible patients.
• Develop, implement, and update individualized care plans in collaboration with cardiologists, advanced practice providers, primary care providers, and other care-team members.
• Review reported symptoms, home blood pressure, heart rate, weight, oxygen saturation, medication adherence, and remote-monitoring data.
• Identify changes in clinical condition, provide patient guidance within established protocols, and promptly elevate urgent concerns to the appropriate provider.
• Educate patients and caregivers on cardiac diagnoses, medications, symptom monitoring, diet, sodium and fluid restrictions, activity, and when to seek emergency care.
• Coordinate appointments, referrals, diagnostic testing, specialty consultations, and community resources.
• Support transitions of care after hospitalizations, emergency department visits, and cardiac procedures.
• Perform medication reconciliation and help address barriers to medication adherence.
• Communicate and coordinate with patients, families, providers, pharmacies, hospitals, home health agencies, and other care partners.
• Document all telehealth encounters, care-management activities, care plans, interventions, patient communications, and required time in the electronic health record.
• Maintain compliance with HIPAA, organizational policies, telehealth standards, and applicable payer documentation requirements.
• Participate in quality-improvement, population-health, and patient-outreach initiatives.

• Current, active, unrestricted Registered Nurse (RN) license in the applicable state.
• Graduation from an accredited nursing program.
• Strong communication, clinical assessment, documentation, and care-coordination skills.
• Ability to work independently while collaborating with an interdisciplinary cardiology team.

• Experience in cardiology, ambulatory care, care management, case management, chronic disease management, or telehealth.
• Familiarity with electronic health records and remote patient-monitoring platforms.