RPM Case Manager

East Central District Health Department/Good Neighbor Community Health Center•Columbus, NE

6d•Remote

About The Position

The Remote Patient Monitoring Case Manager is responsible for coordinating and completing Good Neighbor Community Health Center’s Rural Health Transformation Program Initiative 4.4b Remote Patient Monitoring work plan. This position supports the launch, daily coordination, patient engagement, vendor coordination, device logistics, data tracking, and grant reporting activities needed to establish a sustainable Remote Patient Monitoring program for patients with chronic disease and elevated risk following hospital or emergency department encounters. The position helps patients enroll in the program, understand their devices, stay engaged, and connect with the appropriate clinical team members when alerts, trends, barriers, or care needs are identified.

Requirements

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.

Nice To Haves

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.

Responsibilities

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.