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RN Navigator - Remote Patient Monitoring

Company: Christus Health
Location: Tyler
Posted on: October 9, 2021

Job Description:



The RN RPM Navigator is a member of the patient's care team and acts as a patient advocate providing remote patient monitoring activities for patients with identified infectious diseases or chronic illness as specified by physician order. The RN RPM Navigator facilitates communication and coordinates care with physicians, the providers' clinic, hospital facilities, family, caregivers and other community healthcare providers to meet members/ healthcare needs without compromising quality of outcomes. The RN RPM Navigator will respond to the physician enrollment order from the acute care and/or ambulatory setting as appropriate.

The position responsibilities also include supporting health risk reduction through goal setting, behavioral change, patient education, and identification of social determinants with appropriate community referrals. In addition, the RN RPM Navigator focuses on reducing preventable admissions, re-admissions, and preventable ED visits by supporting the next level of care and educating patients regarding the appropriate setting for care. The RN RPM Navigator connects the patient to health care providers and community resources to ensure ongoing quality of care. The nurse also promotes optimal person-centered care that supports and empowers individuals, respects individual choices and meets health care needs of patients. Ensures smooth transition of care along the continuum. Demonstrates expertise in navigating electronic medical record and other remote patient monitoring applications. Monitors patient vital sign activities, patient disease specific surveys, and social determinants of health surveys and provides feedback to patients regarding protocol recommendations for ongoing support in disease management. The focus of this position is:

  • To ensure quality patient care across the continuum, reduce avoidable readmissions, and improve outcomes for the highest risk individuals.
  • To provide high level nursing care through the ability to perform phone triage and intervene or escalate appropriately using critical thinking skills for complex adult populations.
  • To ensure appropriate screening of patients in need of remote patient monitoring services prior to hospital discharge.
  • To provide patient education appropriate to diagnosis.
  • To provide community resources appropriately in order to prevent hospital readmissions by collaborating with care coordination services.
  • Plan and conduct intervention opportunity evaluations, respond to urgent alerts and remote patient monitoring alerts as needed to help drive high quality care at a lower cost
  • Work directly with the member, via various forms of communication, texting, virtual visits, and telephone, to develop and achieve acute & chronic care management goals
  • Develop and update care plans for members while keeping a close eye on caregiver support
  • Apply clinical experience and judgment to the utilization management/care management activities
  • Collaborate with facility resources and vendors to promote quality outcomes, optimize service experience, and promote effective use of resources for complex or elevated medical issues
  • Participate in quality management/performance improvement activities
  • Facilitates communication and provides care coordination along the continuum of care including inpatient care team as well as the physician and community care team.
  • Ensures appropriate management/stabilization of acute & chronic medical conditions to prevent readmission and promote optimal outcomes.
  • Ability for timely completion of initial assessment and plan of care including the patient, their support system, physician and other health team members to address condition, social determinants, and promote patient knowledge and behavior change.
  • Demonstrates the confidence, drive and ability to face and overcome obstacles to achieve organizational goals.
  • Exhibits behaviors and actions which create a high level of patient satisfaction, contributes to positive patient relations and reflects respect for a patient's rights, needs and confidentiality.
  • Perform ongoing essential Care Coordination activities of assessment, barrier and strengths identification, planning, implementation, coordination, monitoring, and evaluation of patients. Implements practice/action to overcome barriers to care.
  • Documents all communication and responses to patients, Meets all general requirements, annual competencies, and maintains knowledge of all regulatory Federal, State, and Local regulations.
  • Demonstrates effective communication and human relations skills that promote harmony and teamwork.
  • Presents behaviors and actions that maintain credibility, integrity, and positive image.
  • Demonstrates behaviors and actions that support the mission, goals, and operations of the CHRISTUS Health System and which contribute to continuous quality improvement.
  • Maintains a positive attitude and exhibits flexibility in work hours, duties, and job requirements; willingness to perform other duties as assigned.
  • Identifies and outreaches to eligible patients in hospital setting or per phone outreach. 
  • Works collaboratively with team members in the enrollment process.
  • Coaches patients and caregivers toward self-management.
  • Confirms appointment has been made with PCP within 7-14 days post-discharge
  • Performs updates EHR, and communicates with provider.
  • Performs follow up calls as per program.
  • Completes required documentation and tracking of data. 
  • Makes appropriate referrals for medication assistance, transportation, Home Health, DME, and other medical and non-medical needs.


  • BSN Preferred
  • 3-5 years acute care/clinical experience
  • 2-3 years managed care and/or care management experience
  • Experience with high level communication
  • Ability to lead interdisciplinary teams
  • Ability to serve as a patient advocate
  • Texas RN License Required

Work Type: 

Full Time

Keywords: Christus Health, Tyler , RN Navigator - Remote Patient Monitoring, Other , Tyler, Texas

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