About this role
Remote day-shift health coach role supporting patients with chronic conditions through chronic care management. You will coach patients to follow care plans, monitor adherence, escalate changes, and communicate abnormal findings to the cardiology care team using the EMR and CCM platform.
Key Responsibilities
- Develop and maintain a patient coaching relationship supporting the care plan
- Communicate abnormal findings to the cardiology care team
- Monitor and encourage patient adherence and participation in care plans
- Support enrollment for new patients and act as a liaison to practice/providers
- Work effectively with EMR and CCM platform, including protocol adherence and escalation of changes
Technical Overview
This role is workflow-driven around healthcare technology: using the CCM platform and EMR systems (Athena, NexGen, GEMMS, and e-clinical works). You will perform basic CCM platform monitor troubleshooting with patients and ensure protocol-compliant documentation and reporting.
Ideal Candidate
The ideal candidate has 1+ year of experience in remote chronic care management and direct experience with cardiology patients, specifically heart failure. They are an RN (or MA/CNA per the posting) comfortable using EMRs and the CCM platform (including Athena, NexGen, GEMMS, and e-clinical works) while coaching patients to follow care plans and reporting abnormal findings to the care team.
Must-Have Skills
1 year of experience in remote chronic care managementExperience with cardiology patients - specifically heart failureRegistered Nurse (RN)Medical Assistant (MA)Certified Nurse Assistant (CNA)Experience with EMRs – specifically AthenaNexGenGEMMS and e‑clinical worksAbility to follow clinical protocolsWorks effectively with the EMR and CCM platform
Nice-to-Have Skills
Basic monitor troubleshooting with patients for the CCM platform
Tools & Platforms
EMR (Electronic Medical Records)CCM platformAthenaNexGenGEMMSe-clinical worksElectronic Medical Records
Required Skills
chronic care managementpatient coaching relationshipabnormal findings reportingpatient adherenceenrollment processliaison with providersescalate changesEMRCCM platformmonitor troubleshootingclinical protocolscompliance with state and federal regulationscardiology patientsheart failure
Hard Skills
chronic care managementpatient coaching relationshippatient care plan supportcommunicating abnormal findings to the cardiology care teampatient adherence monitoring and encouragementcommunications findings to the care teamenrollment process support for new patientsliaison with practice and providersescalate changes to providersreduce events such as hospitalizations or urgent care visitsEMR (Electronic Medical Records)CCM platformmonitor troubleshooting with patients for the CCM platformfollow clinical protocolscompliance with state and federal regulations/statutescare for cardiology patientsheart failure
Soft Skills
empathetic support for patients and familiesgreat communicationmulti-taskingability to develop purposeful relationshipstrusted supportclear reporting to the cardiology care teampatient-centered coaching
Certifications
Required
Registered Nurse (RN)
Preferred
Medical Assistant (MA)Certified Nurse Assistant (CNA)
Keywords for Your Resume
Chronic Care Management-Health CoachHealth CoachCCM assistantchronic care managementremote chronic care managementcardiology patientsheart failureRegistered Nurse (RN)Medical Assistant (MA)Certified Nurse Assistant (CNA)EMRsElectronic Medical RecordsAthenaNexGenGEMMSe-clinical worksCCM platformpatient coaching relationshipcare planpatient adherenceabnormal findingscardiology care teamenrollment processliaisonescalate changeshospitalizationsurgent care visitsclinical protocolsstate and federal regulations401(k)
Deal Breakers
Must have 1 year of experience in remote chronic care management, Must have experience with cardiology patients specifically heart failure, Must be a Registered Nurse (RN)
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