[Hiring] Care Management Coach - Cardiac Rehab @Aviary

Role Description

The Care Coach conducts regular patient outreach, monitors symptoms and clinical status, provides education on Heart Failure self-management, identifies barriers to care, and facilitates timely escalation of clinical concerns when appropriate. Through ongoing coaching, support, and education, the Care Coach helps patients build the knowledge, confidence, and healthy behaviors necessary to successfully prepare for and transition into Aviary Health's Virtual Cardiac Rehabilitation Program. This role plays a critical part in improving patient outcomes, reducing avoidable hospitalizations, and ensuring patients are engaged, informed, and clinically prepared throughout their Heart Failure journey.

Key Responsibilities

• Conduct telephonic and virtual care management for patients with heart failure.
• Review and assess patients' medical, functional, and psychosocial needs remotely.
• Reinforce heart failure self-management education.
• Coordinate care transitions between healthcare providers and settings.
• Manage an agreed-upon roster of patients each week, ensuring care management activities are completed in a timely manner.
• Collaborate with providers, specialists, and care teams to optimize patient care.
• Schedule and manage follow-up appointments.
• Assist in supporting care transitions and reducing hospital readmissions.
• Educate patients and families about heart failure management and available resources.
• Support patients in self-management and behavior modification interventions.
• Conduct motivational interviewing to encourage lifestyle changes.
• Maintain accurate and timely documentation in electronic health records (EHR).
• Ensure services are provided in accordance with Care Management program requirements and protocols.
• Adhere to applicable confidentiality, privacy, and data security requirements.

Qualifications

• Bachelor's degree in Nursing, Exercise Science, or a related healthcare field.
• Licensed Practical Nurse (LPN), Certified Exercise Physiologist preferred.
• Current CPR certification.
• Minimum of 2 years of experience in chronic care management or a related healthcare setting.
• Experience working with patients with cardiovascular disease and heart failure is preferred.
• Experience working with older patient population.
• Strong knowledge of cardiovascular disease and heart failure management.
• Excellent communication and interpersonal skills.
• Ability to work independently and as part of a healthcare team.
• Proficiency in using electronic health records and other healthcare technology.

Work Environment

• This is a fully remote position, allowing flexibility in work location.
• Must have a reliable internet connection and a suitable home office environment.

Note: This is a 1099 Contractor position only.