Background: Youth in rural areas are disproportionally affected by pediatric obesity. Given the unique barriers rural populations face, tailoring and increasing access to obesity interventions is necessary. This study evaluated the effectiveness of a family-based pediatric obesity intervention delivered to rural children via televideo to a participant's home (iAmHealthy). Methods: Participating schools (n = 18) were randomly assigned to iAmHealthy or a newsletter control group. iAmHealthy is a family-based obesity intervention consisting of biweekly individual health coaching and 8 weekly group sessions followed by six monthly group sessions. Child height/weight and physical activity (MVPA) were assessed at baseline, post-treatment (8 months) and follow-up (20 months). Multi-level modeling accounting for the study's nested design estimated the effect of treatment on outcomes at both timepoints. Results: 148 youth (Mage = 8.9; 56.8% female; 87.1% White) were randomized to iAmHealthy (n = 64) or the control group (n = 84). For child BMIz change, the control group had a marginally significant increase, F (1,130) = 3.82, p = 0.053, from baseline to post and a significant increase, F(1,121) = 12.88, p < 0.001, from baseline to follow-up. The iAmHealthy group had no significant changes in BMIz from baseline to post or follow-up. For average daily MVPA, no differences were observed from baseline to post in either group; however, from baseline to follow-up a significant decrease was observed in the control group (F (1,97) = 20.59, p < 0.001), while iAmHealthy had no significant changes. Conclusions: This trial extends previous pediatric obesity work in an innovative direction by increasing convenience (moving the mHealth intervention into rural family homes) and dose of treatment. Results at follow-up suggest improved BMIz trajectories and long-term health behaviors for youth in the iAmHealthy group compared to the control group.