RN Clinical Care Coordinator - Remote Patient Monitoring

Summary : Job Summary : The RN Care Coordinator - Remote Patient Monitoring (RPM) functions as a registered nurse responsible for monitoring, managing, and coordinating care for patients enrolled in remote patient monitoring programs, with a primary focus on chronic disease management, including hypertension, diabetes, and other identified population health initiatives. Through regular review of patient-generated health data, multidisciplinary collaboration, patient outreach, education, and clinical intervention, the RN Care Coordinator supports patients in achieving improved health outcomes and adherence to treatment plans. In addition to RPM responsibilities, the RN Care Coordinator may assist with care coordination activities for high-risk patients or those with chronic diseases, support quality improvement and population health initiatives, participate in patient outreach campaigns, and contribute to projects focused on improving clinical quality measures and patient engagement. The role may also provide coverage for traditional RN Care Coordinator duties as operational needs require, including direct patient care, care plan development, vaccine and injectable medication administration, and assistance with diagnostic procedures (e.g., spirometry, diabetic retinal imaging, etc.)

Full time Position: Yes, onsite

Reports to : Clinical Pharmacy and Allied Health Manager

Supervises : N o

Dress Requirement : Business Casual in accordance to Heart of Ohio Family Health dress code.

Work Schedule :

Monday through Friday during standard business hours

Times are subject to change due to business necessity

Exempt

Job Duties , these are considered essential to the successful performance of this position:

- Monitor and manage patients enrolled in Remote Patient Monitoring (RPM) programs, primarily for blood pressure and blood glucose management.

- Review, assess, and document patient-generated health data; communicate with patients and providers regarding abnormal readings and facilitate appropriate follow-up.

- Enroll eligible patients in RPM programs and provide education on equipment use, self-monitoring, chronic disease management, medication adherence, and lifestyle modifications.

- Conduct patient outreach related to chronic disease management, preventive care, quality measures, population health initiatives, and medication adherence.

- Support medication access and adherence through interventions such as prior authorizations, medication assistance programs, refill outreach, and related quality improvement projects.

- Collaborate with patients, families, providers, and interdisciplinary team members to establish health goals, coordinate care, and connect patients with needed services, referrals, screenings, labs, and community resources.

- Serve as a primary contact, advocate, and educational resource for patients and caregivers participating in RPM and care coordination programs.

- Support transitions of care following hospitalizations, emergency department visits, and other acute care events as assigned.

- Participate in quality improvement, population health, workflow development, and value-based care initiatives, including data collection, patient outreach, and performance improvement activities.

- Provide coverage for RN Care Coordinator duties as operational needs require, including nursing assessments, care plan development, direct patient care, vaccine and medication administration, diagnostic procedures, and other RN-level clinical responsibilities.

- Maintain accurate and timely documentation and assist with clinical incident review and follow-up as appropriate.

- This job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities required of the employee. Duties, responsibilities, and activities may change, or new ones may be assigned at any time with or without notice.

Equipment Operated :

Telephone & Fax

Computer & Printer

Blood Glucose Monitor

Blood Pressure Machines

Waived function testing

Pulse oximeter

EKG

Centrifuge

NST machine

Oxygen

Audiometer

Audio Visual

HBA1C analyzer

Ultrasound

Other office and medical equipment as assigned

Facility Environment :

Heart of Ohio Family Health operates in multiple locations, in the Columbus, OH area. All facilities have a medical office environment with front-desk reception area, separate patient examination rooms, nursing stations, pharmacy stock room, business offices, hallways and private toilet facilities. All clinical facilities are ADA compliant.

This positions primary work area is the clinical portion of the facility; ie, patient examination rooms, hallways, and other clinically assigned areas.

The clinical area is:

- kept at a normal working temperature

- sanitized daily

- maintains standard environment furniture with adjustable chairs

- maintains standard office equipment; ie, computer, copier, fax machine, etc. at a normal working height

Physical Demands and Requirements : these may be modified to accurately perform the essential functions of the position:

- Mobility = ability to easily move without assistance

- Bending = occasional bending from the waist and knees

- Reaching = occasional reaching no higher than normal arm stretch

- Lifting/Carry = ability to lift and carry a normal stack of documents and/or files

- Pushing/Pulling = ability to push or pull a normal office environment

- Dexterity = ability to handle and/or grasp, use a keyboard, calculator, and other office or medical equipment accurately and quickly

- Hearing = ability to accurately hear and react to the normal tone of a persons voice

- Visual = ability to safely and accurately see and react to factors and objects in a normal setting

- Speaking = ability to pronounce words clearly to be understood by another individual

Qualifications

Job Qualifications (Experience, Knowledge, Skills and Abilities)

Education: Bachelor's degree in nursing.

Experience: 0-3 years clinical care experience. Ambulatory or primary care nursing preferred. Hospital-based nursing acceptable. Ideal candidate has case management experience and experience working with patients with chronic diseases or complex health issues. Candidates must have valid drivers license, reliable transportation, and maintain CPR certification.

Registration/Licensure: Current RN License