RPM Nurse (Remote Patient Monitoring Expert)

We are seeking experienced LPN or RN to join our growing virtual care team delivering Remote Patient Monitoring (RPM) and Chronic Care Management (CCM) services to patients with multiple chronic conditions (diabetes, hypertension, CHF, COPD, CKD, etc.). As a fully remote RPM/CCM Nurse, you will serve as the primary clinical point of contact for an assigned panel of 250–350 high-risk patients, providing monthly non-face-to-face care coordination, medication reconciliation, symptom monitoring, patient education, and remote physiologic data review to prevent exacerbations, reduce hospitalizations, and improve quality of life. You'll work with a team of mobile Medical Assistants and remote nurses who will assist with various aspects of patient contact, care plan management, condition management and provider facing interaction. You'll also be responsible to monitor Labs on a daily basis for all lab submissions the previous day.

Conduct monthly (minimum 20-minute) CCM telephonic or secure messaging encounters, comprehensively documenting time and clinical content in the EHR to meet CMS billing requirements (CPT 99490, 99439, 99487, 99489, 99491, etc.). Enroll eligible patients into CCM and RPM programs, obtain verbal/written consent, and create personalized care plans in collaboration with the patient’s primary care provider. Review and act on daily remote physiologic monitoring data (blood pressure, blood glucose, weight, pulse oximetry, etc.) transmitted via cellular-connected devices; escalate abnormal readings according to evidence-based protocols. Perform medication reconciliation, identify barriers to adherence, coordinate refills, and close gaps in care. Facilitate transitions of care after hospitalizations or ED visits (TCM when applicable). Coordinate with primary care providers, specialists, home health, DME suppliers, and community resources. Achieve quality metrics and utilization goals (e.g., reduced 30-day readmissions, improved HbA1c, BP control, patient satisfaction). Maintain meticulous documentation for auditing and compliance with CMS and NCQA standards. Participate in daily huddles, weekly case conferences, and ongoing training.