Chronic Care/Remote Monitoring Coordinator
Who We Are: Vis-À-Vis Health is a comprehensive care solution, providing physician services in the community as well as in Skilled Nursing Facilities. Vis-À-Vis Health provides convenient access to high-quality medical care to patients within the house call setting in a compassionate, complete, comprehensive, and cost-effective manner. We are focused on creating a revolutionary patient-centric healthcare model that leverages technology to generate positive healthcare outcomes and savings with the help of our medical teams. Job Description: The RPM/CCM Coordinator, Community plays a dual-function role in supporting both the Remote Patient Monitoring (RPM) and Chronic Care Management (CCM) programs. This individual acts as a key connector between patients, providers, and internal care teams. The coordinator is responsible for managing patient care plans, conducting outreach and education, monitoring vitals and care adherence, and escalating concerns to clinical staff as appropriate. Duties/Responsibilities:
- Conduct monthly outreach to patients with chronic conditions to review health status and support care plan adherence.
- Assist in developing and maintaining individualized care plans.
- Collaborate with physicians, nurses, and other team members to ensure coordinated, high-quality care.
- Educate patients on chronic condition management and available resources.
- Ensure documentation meets Medicare CCM compliance standards.
- Monitor patient vitals using our tech-enabled RPM platform and flag abnormal trends.
- Conduct check-in calls to reinforce engagement with monitoring protocols.
- Escalate concerns to Nurse Practitioners or Primary Care Providers based on clinical criteria.
- Assist patients with using their monitoring equipment correctly.
- Coordinate transitions of care and maintain proactive communication with patients and families.
- Document all patient interactions, care coordination efforts, and escalation actions in the EHR.
- Collaborate with RN Care Managers and other clinical stakeholders for triage and follow-up.
- Participate in team huddles, skill-building workshops, and ongoing workflow optimizations.
- Provide exceptional service and maintain positive patient relationships.
Required Skills/Abilities:
- Strong communication and interpersonal skills for engaging with patients, families, and interdisciplinary teams.
- Detail-oriented with the ability to multitask and prioritize in a fast-paced, remote environment.
- Comfortable with telephonic outreach and motivational interviewing techniques.
- Proficient in EHR systems, RPM platforms, and Microsoft Office Suite.
- Understanding of Medicare CCM/RPM compliance guidelines and chronic condition education.
- Experience in vital trend analysis and clinical triage workflows a strong plus.
Education and Experience:
- Certified Medical Assistant preferred but not required.
- Associate’s or Bachelor’s degree in healthcare, nursing, social work, or a related field preferred.
- 1–2 years of experience in care coordination, Chronic Care Management, Remote Patient Monitoring, or telehealth.
- Experience working with adult/geriatric populations with chronic and co-occurring conditions is highly desirable.
Benefits (Full-time Providers)
- 401(k)
- Dental insurance
- Health insurance
- Vision insurance
- Paid time off
Salary Range: $35,000 annual base salary + RVU Work Location: Remote Employment Status: Full-Time Pay Grade: Hourly FLSA Status: Non-exempt Vis-À-Vis Health recognizes and values the key to success is the experiences and perspectives of people from all walks of life. Vis-À-Vis Health is proud to be an equal employment opportunity employer to all individual, regardless of their race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, or any other characteristic protected by state, federal, or local law. Apply To this Job