RN Navigator - Remote Patient Monitoring
Company: Christus Health
Posted on: October 9, 2021
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
- 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
- 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
- Participate in quality management/performance improvement
- 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
- 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
- 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
- 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
- Documents all communication and responses to patients, Meets
all general requirements, annual competencies, and maintains
knowledge of all regulatory Federal, State, and Local
- 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
- Coaches patients and caregivers toward self-management.
- Confirms appointment has been made with PCP within 7-14 days
- Performs updates EHR, and communicates with provider.
- Performs follow up calls as per program.
- Completes required documentation and tracking of
- Makes appropriate referrals for medication assistance,
transportation, Home Health, DME, and other medical and non-medical
- 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
Keywords: Christus Health, Tyler , RN Navigator - Remote Patient Monitoring, Other , Tyler, Texas
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