RN Remote Patient Monitoring (RPM) & Chronic Care Management (CCM)

The Registered Nurse (RN) provides clinical oversight and patient care management
within Remote Patient Monitoring (RPM) and Chronic Care Management (CCM)
programs. This role focuses on evaluating patient data, coordinating care, and
supporting patients with chronic conditions through ongoing monitoring and
engagement. The RN collaborates with providers and care teams to improve patient
outcomes, reduce hospitalizations, and ensure high-quality, compliant care delivery.

Key Responsibilities
 Review and interpret patient-generated health data (e.g., blood pressure,
glucose, pulse oximetry, weight) from RPM platforms
 Assess patient conditions and identify trends, risks, or abnormalities requiring
intervention
 Develop, implement, and update individualized care plans in collaboration with
providers
 Conduct routine and as-needed patient outreach via phone or telehealth for CCM
and RPM services
 Provide clinical education on disease management, medications, and lifestyle
modifications
 Triage patient concerns and escalate urgent or complex cases to providers as
needed
 Coordinate care among primary care providers, specialists, and other healthcare
team members
 Ensure accurate and timely documentation in the electronic health record (EHR)
 Track and document time and services in compliance with CMS guidelines for
RPM and CCM billing
 Support quality improvement initiatives and patient engagement strategies
 Supervise and support Medical Assistants or care coordinators involved in
RPM/CCM workflows (if applicable)
 Maintain compliance with HIPAA and all regulatory requirements

 Active and unrestricted Registered Nurse (RN) license
 Associate or Bachelor of Science in Nursing (BSN preferred)
 Minimum of 1–3 years of clinical nursing experience (primary care, case
management, or chronic disease management preferred)
 Experience with telehealth, care management, or remote monitoring programs
preferred
 Familiarity with EHR systems and digital health platforms
 Strong clinical assessment and critical thinking skills

Skills & Competencies
 Advanced patient assessment and clinical judgment
 Strong communication and patient education skills
 Care coordination and case management expertise
 Attention to detail and accurate documentation
 Ability to work independently in a remote or hybrid environment
 Proficiency with healthcare technology and data monitoring tools

Work Environment
 Remote, hybrid, or office-based depending on organization
 Frequent use of computers, phones, and remote monitoring dashboards
 High level of patient interaction via phone or telehealth platforms

Physical Requirements
 Prolonged periods of sitting and working on a computer
 Ability to communicate clearly via phone and digital systems

Preferred Experience
 Experience with Medicare CCM/RPM billing and documentation requirements
 Background in population health or care management programs
 Certification in case management (e.g., CCM, RN-BC)
 Experience managing patients with chronic conditions such as diabetes,
hypertension, COPD, or heart failure