VA - RN Case Manager (Northern VA Area)

About the role

Ponos Care is a physician-led, value-based healthcare organization delivering compassionate, holistic care to individuals with complex, chronic, inflammatory and immune-related conditions. The RN Case Manager (TOC / Travel Infusion / RPM / LTSS) supports Medicaid populations through proactive telephonic outreach, comprehensive assessments, and collaboration with interdisciplinary teams, ensuring members receive appropriate case management and care coordination services that promote independence and quality of life.

Responsibilities

• Patient Assessment & Care Planning
  • Conduct complete initial assessments of members via telephonic outreach or in-home visits, including medical history, current health status, LTSS eligibility, functional abilities, caregiver support, and social needs.
  • Develop and implement personalized care plans addressing medical, behavioral health, social determinant, and infusion therapy needs in collaboration with the member, family, and interdisciplinary care team.
  • Reassess member conditions continuously and modify care plans as needed to ensure effective care transitions.
• Clinical Care & Infusion Services
  • Administer infusion therapies and acute pain management treatments in members’ homes or community settings, including IV line placement, medication administration, and monitoring of vital signs and patient responses.
  • Implement preventive and rehabilitative nursing procedures during in-person visits to support long-term health outcomes.
  • Monitor remote patient monitoring feeds for triggers requiring clinical interventions.
• Member Education & Advocacy
  • Educate members and families on treatment plans, medications, disease management, and preventive care strategies.
  • Provide counseling, holistic wellness coaching, and advocacy to ensure culturally competent care aligned with member values.
• Case Management & Care Coordination
  • Coordinate clinical services and resources across the continuum of care, working with providers, specialists, and community-based organizations.
  • Facilitate smooth transitions of care, including post-hospital discharge follow-up.
  • Conduct regular outreach to monitor adherence to care plans and proactively address barriers to care.
  • Triage and escalate high-risk findings or urgent clinical/behavioral health concerns per established protocols.
  • Ensure timely communication among care team members, including PCPs and specialists.
  • Identify and connect members with community-based programs and social services to address social determinants of health.
• Documentation & Quality
  • Document all member assessments, care plans, outreach calls, visits, interventions, and outcomes promptly and accurately in EHR/EMR systems.
  • Ensure documentation and care coordination activities meet organizational, audit, and regulatory standards (e.g., CMS, NCQA, HEDIS).
  • Participate in quality improvement initiatives and monitor patient outcomes.
• Program Development & Innovation
  • Contribute to developing and refining case management and mobile infusion care policies, procedures, and workflows.
  • Identify and implement innovative approaches to expand telehealth and home-based infusion services.
  • Support value-based care goals by proposing best practices in care coordination and infusion therapy.
• Regulatory & Compliance
  • Ensure full compliance with federal and state nursing regulations, CMS guidelines, and healthcare quality standards.
  • Maintain patient privacy and confidentiality in accordance with HIPAA and organizational standards.
  • Follow all safety procedures for infusion therapy and medication administration.

Qualifications

• Education & Licensure
  • Bachelor’s degree in nursing (BSN) or equivalent required.
  • Active multistate Registered Nurse (RN) license in all state(s) of practice.
  • CPR/BLS certification required.
• Experience
  • Minimum 2+ years of clinical nursing experience in care management, population health, acute care, infusion therapy, hematology, pain management, or community health.
  • Experience serving Medicaid or complex care populations preferred.
  • Knowledge of Long-Term Support Services preferred.
• Certifications
  • Certified Case Manager (CCM) preferred.
  • Additional specialty certifications such as ACLS, ONCC, or CRNI highly desirable.
• Skills
  • Strong clinical, communication, and critical-thinking skills with proven ability to manage a complex caseload in a remote/hybrid environment.
  • Expertise with electronic health record systems and remote patient monitoring technology preferred.
• Other Requirements
  • Active driver’s license and willingness to travel to patient homes across assigned regions.
  • Commitment to health equity and delivery of culturally competent care in diverse communities.
  • Bilingual proficiency is a plus.