RPM Case Manager

POSITION SUMMARY:

ESSENTIAL JOB FUNCTIONS:

• Coordinate completion of the Remote Patient Monitoring work plan, including implementation milestones, patient enrollment workflows, device deployment, reporting, and sustainability activities.
• Serve as the primary day-to-day coordinator for Remote Patient Monitoring onboarding, patient engagement, device logistics, inventory tracking, vendor communication, and work plan documentation.
• Support identification, referral, and enrollment of eligible patients, including patients with hypertension, diabetes, COPD, heart failure, post-hospital discharge needs, emergency department follow-up needs, or other clinically appropriate risk factors.
• Contact referred patients; explain program expectations in plain language, obtain required consents, document enrollment activity, and assist patients with device setup and routine use.
• Coordinate hospital-to-home workflows with Good Neighbor clinical teams, hospitals, emergency departments, referral partners, and community partners to support timely follow-up after discharge or acute events.
• Evaluate referred patients for Remote Patient Monitoring eligibility within 5 to 7 days of receiving the referral, according to approved program criteria and clinical team direction.
• Conduct patient outreach within 48 hours of identified hospital admission, emergency department visit, or referral when the patient is enrolled in or being evaluated for the program.
• Maintain regular patient engagement, including monthly contact goals, troubleshooting support, missed reading follow-up, barrier identification, appointment coordination, and referral to internal or community resources as appropriate.
• Monitor Remote Patient Monitoring dashboards and vendor reports for participation, missing data, device issues, and non-clinical alert routing needs. Escalate clinical concerns to the appropriate licensed clinical team member in accordance with approved protocols.
• Support implementation of clinical monitoring protocols and escalation pathways by ensuring alerts, trends, and patient-generated information are documented and routed appropriately. This position does not diagnose, treat, or make independent clinical decisions.
• Coordinate deployment, return, storage, cleaning, replacement, and tracking of Remote Patient Monitoring devices and related supplies, including blood pressure cuffs, scales, glucometers, pulse oximeters, tablets, hubs, batteries, adapters, and accessories.
• Maintain accurate inventory records, asset tracking logs, shipping records, consent documentation, patient education materials, and other implementation records needed for grant compliance and operational accountability.
• Work with internal and external stakeholders to support user access, reporting tools, data flow, device connectivity, and workflow improvements.
• Enter and maintain timely documentation as appropriate in the clinic-preferred EHR, spreadsheets, dashboards, or other approved systems according to organizational procedures.
• Assist in developing and maintaining patient education packets, translated instructional materials, consent forms, onboarding guides, workflow tools, training materials, program protocols, and standard operating procedures.
• Track and report required program metrics, including patient enrollment, monthly patient contact rates, outreach following hospital or emergency department visits, referral evaluation timeliness, 90-day retention, device utilization, and other grant or quality measures.
• Prepare routine updates for supervisors, leadership, finance, quality improvement teams, HCAN, and grant reporting, including barriers, progress toward milestones, patient engagement results, and recommended improvements.
• Participate in vendor meetings, HCAN trainings, project coordination meetings, internal workgroups, department meetings, and other training opportunities needed to complete the work plan and strengthen program performance.
• Work cooperatively with providers, nurses, medical assistants, care coordinators, outreach staff, front office staff, finance, procurement, IT, and community partners to support patient access, chronic disease management, and program sustainability.
• Protect patient privacy and confidential information at all times, including compliance with HIPAA, organizational policies, consent requirements, data sharing procedures, and information security standards.
• Perform all other duties as assigned.

EDUCATION:

• High School Diploma or equivalent required.
• Associate’s or Bachelor’s Degree in Healthcare Administration, Public Health, Human Services, Social Work, Nursing, Medical Assisting, Health Information, or a closely related field preferred. Equivalent combinations of education and experience may be considered.
• Previous experience in care coordination, case management, community health, chronic disease management, patient navigation, medical office operations, public health, grant funded programs, or health care project coordination preferred.
• LPN, RN, Medical Assistant, Community Health Worker, or related health care credential preferred but not required when the candidate has strong coordination and patient engagement experience.
• Willingness to complete Remote Patient Monitoring, HIPAA, patient engagement, device training, vendor training, and other required program training.

• High School Diploma or equivalent required.
• Associate’s or Bachelor’s Degree in Healthcare Administration, Public Health, Human Services, Social Work, Nursing, Medical Assisting, Health Information, or a closely related field preferred. Equivalent combinations of education and experience may be considered.
• Previous experience in care coordination, case management, community health, chronic disease management, patient navigation, medical office operations, public health, grant-funded programs, or health care project coordination preferred.
• Willingness to complete Remote Patient Monitoring, HIPAA, patient engagement, device training, vendor training, and other required program training.

PREFERRED SKILLS:

• Clinical licensure - LPN, RN, Medical Assistant, Community Health Worker, or related health care credential preferred but not required when the candidate has strong experience in coordination and patient engagement.
• Experience with NextGen, Azara DRVS, Remote Patient Monitoring platforms, patient registries, population health tools, and/or electronic health records.
• Experience supporting patients with hypertension, diabetes, COPD, heart failure, behavioral health needs, or other chronic conditions.
• Experience with grant reporting, quality improvement, workflow development, inventory management, or vendor coordination.
• Bilingual fluency in Spanish, or another language commonly spoken by patients served by Good Neighbor Community Health Center preferred.

• This position does not have any direct reports.

PHYSICAL REQUIREMENTS:

• Prolonged periods of sitting may be required.
• Occasional bending, lifting, stooping, and stretching.
• Normal hearing and vision required.
• Ability to maintain eye-hand coordination and manual dexterity to operate office equipment (e.g., computer keyboard, telephone, photocopier, calculator).
• Ability to lift up to 35 pounds as needed.

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