Johanna Osorio
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Lead Nurse – Chronic Care Management (CCM) & Remote Patient Monitoring (RPM)
Miami, Florida, United States
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Manager of NursingVivo CareAug 2026 - Current (3 months)- Lead Nurse – Chronic Care Management (CCM) & Remote Patient Monitoring (RPM)Vivo CareSep 2025 - Aug 2026 (1 year)• Oversee delivery of monthly CCM services, ensuring regulatory compliance, quality documentation, and achievement of productivity standards.
• Supervised monitoring and escalation of abnormal RPM alerts (BP, glucose, pulse oximetry, weight), coordinating timely interventions and provider communication.
• Directed development and implementation of patient-centered care plans aligned with provider goals and evidence-based practice.
• Ensured accurate medication reconciliation and delivered chronic disease education to prevent avoidable hospitalizations.
• Provided ongoing coaching, performance feedback, and clinical guidance to Clinical Nurses/Care Coordinators, improving quality scores and productivity metrics.
• An - CCM/RPM LPN Care NavigatorVivo CareAug 2025 - Sep 2025 (2 months)Provide Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) services through monthly patient outreach, individualized care plan development, medication reconciliation, chronic disease education, and ongoing care coordination. Knowledgeable in CCM and RPM billing requirements, documentation standards, and applicable billing codes. Monitored RPM data, collaborated with providers, connected patients with community resources, and promoted improved health outcomes through continuous patient engagement. Bilingual (English/Spanish) with experience developing personalized care plans, training and shadowing new nurses, and providing clinical mentorship to support team success.
- RPM/CCM LPN Care NavigatorOptimize HealthAug 2024 - Aug 2025 (1 year 1 month)Provide Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) services through monthly patient outreach, individualized care plan development, medication reconciliation, chronic disease education, and ongoing care coordination. Knowledgeable in CCM and RPM billing requirements, documentation standards, and applicable billing codes. Monitored RPM data, collaborated with providers, connected patients with community resources, and promoted improved health outcomes through continuous patient engagement. Bilingual (English/Spanish) with experience developing personalized care plans, training and shadowing new nurses, and providing clinical mentorship to support team success.