VA - RN Case Manager (Northern VA Area)
for section headings. Use - for any list of duties/requirements/benefits, and
for prose. Do not repeat job title as heading. Do not put Job ID/requisition numbers. Remove boilerplate like EEO statement. Also remove duplicated lines. Need to preserve all substantive information.
We need to decide sections: About the role (maybe from Organizational Overview and Position Overview). Responsibilities (Core Responsibilities). Requirements (maybe Qualifications and Education). Skills (Skills section). Possibly also include "Qualifications" separate from Requirements? The instruction says use headings like About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. We can combine Requirements and Qualifications? But they are separate headings. We need to include a section only when posting has real specific content for it. The posting has Qualifications and Education (education, licensure, experience, certifications). It also has Skills section. It also has maybe Requirements? The posting doesn't have a separate "Requirements" heading but we could treat Qualifications as Requirements? However we need to follow instruction: Use headings exactly as given. If we include Requirements, we need content. The posting does not have a separate "Requirements" section; but we could put the qualifications under Requirements? But then we would duplicate. Better to include Qualifications and Skills sections, and maybe Requirements could be omitted if no specific content besides qualifications? The instruction: "include a section ONLY when the posting has real, specific content for it". So if we don't have distinct Requirements content beyond what's in Qualifications, we could omit Requirements. But we need to decide.
The posting includes "Qualifications and Education" and "Skills". So we can have headings: About the role, Responsibilities, Qualifications, Skills. Possibly also "Requirements" could be omitted.
We need to preserve all substantive information: organizational overview, position overview, core responsibilities (with subpoints), qualifications and education, skills. Also maybe mention "Core Responsibilities" subheadings like Patient Assessment & Care Planning, Clinical Care & Infusion Services, etc. Should we keep those as subheadings? The instruction only says use
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). It doesn't forbid other headings, but we should follow the pattern. Could we keep subheadings as or ? Not specified. Safer to keep them as maybe, but instruction only mentions using for section headings (the listed ones). It doesn't forbid other headings, but to be safe we could keep them as
with bold? However we need to preserve structure. Could keep them as
but not prohibited. The instruction: "use for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule)." It implies that for those specific sections we should use h3. For other headings maybe we can use h4 or just keep as is. I'll keep subheadings as to differentiate.
We need to use - for any list of duties/requirements/benefits. So for responsibilities we should convert each duty into list items. The responsibilities are described in paragraphs with bullet-like sentences. We'll extract each duty as list items.
We need to preserve all substantive information, not invent or summarize away detail. So we need to keep details like specific conditions, tasks, etc.
Let's parse the posting.
Organizational Overview: first paragraph about Ponos Care. Then "improving outcomes for individuals living with chronic, inflammatory, and immune-related conditions." (maybe duplicate). We'll combine.
Position Overview: description of role.
Core Responsibilities: broken into sections with bullet-like paragraphs.
We'll create About the role section combining Organizational Overview and Position Overview (maybe summarizing but not losing detail). Must preserve all substantive information; we can't summarize away detail, but we can rephrase as long as we keep all info. The instruction: "Preserve ALL substantive information; do NOT invent or summarize away detail." So we cannot omit details, but we can rephrase? Summarizing away detail would be removing detail. Rephrasing while keeping all details is okay. We'll keep the info.
We'll produce
for prose.
For responsibilities, we need to convert each duty into list items. Let's extract duties:
From Core Responsibilities:
Patient Assessment & Care Planning:
- Conduct complete initial assessments of members via telephonic outreach or in-home visits as appropriate, including thorough evaluation of medical history, current health status, LTSS eligibility, functional abilities, caregiver support, and social needs.
- Use findings to identify risks and determine necessary interventions.
- Develop and implement personalized care plans addressing each member’s medical, behavioral health, social determinant, and (if needed) infusion therapy needs, in collaboration with the member, their family, and the interdisciplinary care team.
- Reassess member conditions continuously and modify care plans as needed to reflect changing needs and ensure effective care transitions (e.g., discharge planning after hospitalizations).
Clinical Care & Infusion Services:
- Provide direct clinical care as needed by administering infusion therapies and acute pain management treatments in members’ homes or community settings, performing IV line placements and medication administration in accordance with physician orders and established safety protocols.
- Monitor vital signs and member responses to treatments, making immediate adjustments or interventions as appropriate to ensure patient safety and comfort.
- Implement appropriate preventive and rehabilitative nursing procedures during in-person visits to support long-term health outcomes, including proactive care interventions and reinforcement of self-management skills for chronic condition management.
- Use of RPM (Remote patient monitoring) for high utilizers – monitoring feeds for triggers for clinical interventions.
- Educate members and their families on treatment plans, medications, disease management, and preventive care strategies to promote self-care and independence.
- Provide counseling and holistic wellness coaching as needed and serve as a member advocate to ensure that care is culturally competent and aligned with the member’s values and needs.
Case Management & Care Coordination:
- Coordinate clinical services and resources across the continuum of care by working closely with primary care providers, specialists, and community-based organizations to arrange appropriate treatments, referrals, and support services.
- Facilitate smooth transitions of care (e.g., post-hospital discharge follow-up) to maintain continuity of care.
- Conduct regular outreach to check on members’ progress, monitor their adherence to care plans, and proactively address barriers to care (e.g., scheduling issues, transportation, social challenges).
- Utilize remote patient monitoring tools and data to track health status, identify early signs of deterioration, and prompt timely interventions for chronic disease management.
- Triage and escalate high-risk findings or urgent clinical/behavioral health concerns per established protocols and triggers.
- Ensure timely communication and information sharing among all care team members, including the Primary Care Provider (PCP) and specialists, especially when significant changes occur in a member’s condition or care plan.
- Participate in interdisciplinary team meetings and case reviews to align on care strategies and optimize coordinated care delivery.
- Identify and connect members with relevant community-based programs, social services, and support organizations to address social determinants of health and augment the care plan.
- Follow up to ensure services are accessed and needs are met.
Documentation & Quality:
- Document all member assessments, care plans, outreach calls, visits, interventions, and outcomes promptly and accurately in the electronic health record (EHR/EMR) systems, in accordance with organizational policy and best practices.
- Ensure all documentation and care coordination activities meet organizational, audit, and regulatory standards (e.g., CMS, NCQA, HEDIS requirements), maintaining compliance with patient privacy (HIPAA) and safety protocols.
- Actively participate in quality improvement initiatives and monitor patient outcomes to identify opportunities for better care coordination and performance improvement.
Program Development & Innovation:
- Contribute to developing and refining case management and mobile infusion care policies, procedures, and workflows to enhance efficiency and operational excellence.
- Identify and implement innovative approaches to expand telehealth and home-based infusion services and improve access to care for underserved populations.
- Support Ponos Care’s value-based care goals by proposing and adopting best practices in care coordination and infusion therapy.
- Provide feedback to leadership on clinical outcomes and workflow improvements and assist in scaling successful care models to new regions or patient populations.
Regulatory & Compliance:
- Ensure full compliance with all relevant federal and state nursing regulations, CMS guidelines, and healthcare quality standards in daily practice.
- Strictly adhere to organizational policies, clinical protocols, and documentation requirements to maintain regulatory compliance.
- Maintain patient privacy and confidentiality in accordance with HIPAA and organizational standards.
- Follow all safety procedures for infusion therapy and medication administration to minimize risk and ensure patient safety.
Qualifications and Education:
- 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 relevant settings such as care management, population health, acute care, infusion therapy, hematology, pain management, or community health. Experience serving Medicaid or complex care populations is preferred. Knowledge of Long-Term Support Services is preferred.
- Certifications: Certified Case Manager (CCM) preferred. Additional specialty certifications such as ACLS (Advanced Cardiac Life Support), ONCC (Oncology Nursing), or CRNI (Certified Registered Nurse Infusion) are 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 is 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.
We need to output HTML fragment only.
We'll create sections:
About the role
Organizational overview paragraph(s) + Position overview paragraph(s). Combine.
We need to include all details from Organizational Overview and Position Overview.
Organizational Overview text:
"Ponos Care is a physician-led, value-based healthcare organization committed to delivering compassionate, holistic care to individuals with complex, chronic, inflammatory and immune-related conditions. We integrate social, mental, physical and economic solutions to address the unique needs of our patient populations including those living with sickle cell disease, ulcerative colitis, Crohn’s disease, severe rheumatoid arthritis, lupus, multiple sclerosis and chronic kidney disease. Our mission is to improve health equity and enhance outcomes and quality of life by reducing avoidable emergency department and hospitalizations through comprehensive care coordination, home-based and telehealth services and innovative treatment models. We provide services on a national level in diverse communities, focusing on holistic, member-centered care that promotes independence and well-being for our members. improving outcomes for individuals living with chronic, inflammatory, and immune-related conditions."
Note there is a duplicated phrase at end: "improving outcomes for individuals living with chronic, inflammatory, and immune-related conditions." We'll keep it.
Position Overview text:
"The RN Case Manager (TOC / Travel Infusion / RPM / LTSS (Hybrid / Telephonic Role) supports Medicaid populations through proactive telephonic outreach, comprehensive assessments, and collaboration with interdisciplinary teams. This role helps ensure members receive appropriate case management and care coordination services that promote independence and quality of life. Position Overview The RN Case Manager (TOC / Travel Infusion / RPM / LTSS (Hybrid / Telephonic Role) is a hybrid role integrating telephonic case management and care coordination with travel-based home infusion therapy, TOC, RPM and LTSS responsibilities. In this role, the nurse manages a complex caseload
for prose. Do not repeat job title as heading. Do not put Job ID/requisition numbers. Remove boilerplate like EEO statement. Also remove duplicated lines. Need to preserve all substantive information. We need to decide sections: About the role (maybe from Organizational Overview and Position Overview). Responsibilities (Core Responsibilities). Requirements (maybe Qualifications and Education). Skills (Skills section). Possibly also include "Qualifications" separate from Requirements? The instruction says use headings like About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. We can combine Requirements and Qualifications? But they are separate headings. We need to include a section only when posting has real specific content for it. The posting has Qualifications and Education (education, licensure, experience, certifications). It also has Skills section. It also has maybe Requirements? The posting doesn't have a separate "Requirements" heading but we could treat Qualifications as Requirements? However we need to follow instruction: Use headings exactly as given. If we include Requirements, we need content. The posting does not have a separate "Requirements" section; but we could put the qualifications under Requirements? But then we would duplicate. Better to include Qualifications and Skills sections, and maybe Requirements could be omitted if no specific content besides qualifications? The instruction: "include a section ONLY when the posting has real, specific content for it". So if we don't have distinct Requirements content beyond what's in Qualifications, we could omit Requirements. But we need to decide. The posting includes "Qualifications and Education" and "Skills". So we can have headings: About the role, Responsibilities, Qualifications, Skills. Possibly also "Requirements" could be omitted. We need to preserve all substantive information: organizational overview, position overview, core responsibilities (with subpoints), qualifications and education, skills. Also maybe mention "Core Responsibilities" subheadings like Patient Assessment & Care Planning, Clinical Care & Infusion Services, etc. Should we keep those as subheadings? The instruction only says use
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). It doesn't forbid other headings, but we should follow the pattern. Could we keep subheadings as or ? Not specified. Safer to keep them as maybe, but instruction only mentions using for section headings (the listed ones). It doesn't forbid other headings, but to be safe we could keep them as
with bold? However we need to preserve structure. Could keep them as
but not prohibited. The instruction: "use for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule)." It implies that for those specific sections we should use h3. For other headings maybe we can use h4 or just keep as is. I'll keep subheadings as to differentiate.
We need to use - for any list of duties/requirements/benefits. So for responsibilities we should convert each duty into list items. The responsibilities are described in paragraphs with bullet-like sentences. We'll extract each duty as list items.
We need to preserve all substantive information, not invent or summarize away detail. So we need to keep details like specific conditions, tasks, etc.
Let's parse the posting.
Organizational Overview: first paragraph about Ponos Care. Then "improving outcomes for individuals living with chronic, inflammatory, and immune-related conditions." (maybe duplicate). We'll combine.
Position Overview: description of role.
Core Responsibilities: broken into sections with bullet-like paragraphs.
We'll create About the role section combining Organizational Overview and Position Overview (maybe summarizing but not losing detail). Must preserve all substantive information; we can't summarize away detail, but we can rephrase as long as we keep all info. The instruction: "Preserve ALL substantive information; do NOT invent or summarize away detail." So we cannot omit details, but we can rephrase? Summarizing away detail would be removing detail. Rephrasing while keeping all details is okay. We'll keep the info.
We'll produce
for prose.
For responsibilities, we need to convert each duty into list items. Let's extract duties:
From Core Responsibilities:
Patient Assessment & Care Planning:
- Conduct complete initial assessments of members via telephonic outreach or in-home visits as appropriate, including thorough evaluation of medical history, current health status, LTSS eligibility, functional abilities, caregiver support, and social needs.
- Use findings to identify risks and determine necessary interventions.
- Develop and implement personalized care plans addressing each member’s medical, behavioral health, social determinant, and (if needed) infusion therapy needs, in collaboration with the member, their family, and the interdisciplinary care team.
- Reassess member conditions continuously and modify care plans as needed to reflect changing needs and ensure effective care transitions (e.g., discharge planning after hospitalizations).
Clinical Care & Infusion Services:
- Provide direct clinical care as needed by administering infusion therapies and acute pain management treatments in members’ homes or community settings, performing IV line placements and medication administration in accordance with physician orders and established safety protocols.
- Monitor vital signs and member responses to treatments, making immediate adjustments or interventions as appropriate to ensure patient safety and comfort.
- Implement appropriate preventive and rehabilitative nursing procedures during in-person visits to support long-term health outcomes, including proactive care interventions and reinforcement of self-management skills for chronic condition management.
- Use of RPM (Remote patient monitoring) for high utilizers – monitoring feeds for triggers for clinical interventions.
- Educate members and their families on treatment plans, medications, disease management, and preventive care strategies to promote self-care and independence.
- Provide counseling and holistic wellness coaching as needed and serve as a member advocate to ensure that care is culturally competent and aligned with the member’s values and needs.
Case Management & Care Coordination:
- Coordinate clinical services and resources across the continuum of care by working closely with primary care providers, specialists, and community-based organizations to arrange appropriate treatments, referrals, and support services.
- Facilitate smooth transitions of care (e.g., post-hospital discharge follow-up) to maintain continuity of care.
- Conduct regular outreach to check on members’ progress, monitor their adherence to care plans, and proactively address barriers to care (e.g., scheduling issues, transportation, social challenges).
- Utilize remote patient monitoring tools and data to track health status, identify early signs of deterioration, and prompt timely interventions for chronic disease management.
- Triage and escalate high-risk findings or urgent clinical/behavioral health concerns per established protocols and triggers.
- Ensure timely communication and information sharing among all care team members, including the Primary Care Provider (PCP) and specialists, especially when significant changes occur in a member’s condition or care plan.
- Participate in interdisciplinary team meetings and case reviews to align on care strategies and optimize coordinated care delivery.
- Identify and connect members with relevant community-based programs, social services, and support organizations to address social determinants of health and augment the care plan.
- Follow up to ensure services are accessed and needs are met.
Documentation & Quality:
- Document all member assessments, care plans, outreach calls, visits, interventions, and outcomes promptly and accurately in the electronic health record (EHR/EMR) systems, in accordance with organizational policy and best practices.
- Ensure all documentation and care coordination activities meet organizational, audit, and regulatory standards (e.g., CMS, NCQA, HEDIS requirements), maintaining compliance with patient privacy (HIPAA) and safety protocols.
- Actively participate in quality improvement initiatives and monitor patient outcomes to identify opportunities for better care coordination and performance improvement.
Program Development & Innovation:
- Contribute to developing and refining case management and mobile infusion care policies, procedures, and workflows to enhance efficiency and operational excellence.
- Identify and implement innovative approaches to expand telehealth and home-based infusion services and improve access to care for underserved populations.
- Support Ponos Care’s value-based care goals by proposing and adopting best practices in care coordination and infusion therapy.
- Provide feedback to leadership on clinical outcomes and workflow improvements and assist in scaling successful care models to new regions or patient populations.
Regulatory & Compliance:
- Ensure full compliance with all relevant federal and state nursing regulations, CMS guidelines, and healthcare quality standards in daily practice.
- Strictly adhere to organizational policies, clinical protocols, and documentation requirements to maintain regulatory compliance.
- Maintain patient privacy and confidentiality in accordance with HIPAA and organizational standards.
- Follow all safety procedures for infusion therapy and medication administration to minimize risk and ensure patient safety.
Qualifications and Education:
- 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 relevant settings such as care management, population health, acute care, infusion therapy, hematology, pain management, or community health. Experience serving Medicaid or complex care populations is preferred. Knowledge of Long-Term Support Services is preferred.
- Certifications: Certified Case Manager (CCM) preferred. Additional specialty certifications such as ACLS (Advanced Cardiac Life Support), ONCC (Oncology Nursing), or CRNI (Certified Registered Nurse Infusion) are 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 is 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.
We need to output HTML fragment only.
We'll create sections:
About the role
Organizational overview paragraph(s) + Position overview paragraph(s). Combine.
We need to include all details from Organizational Overview and Position Overview.
Organizational Overview text:
"Ponos Care is a physician-led, value-based healthcare organization committed to delivering compassionate, holistic care to individuals with complex, chronic, inflammatory and immune-related conditions. We integrate social, mental, physical and economic solutions to address the unique needs of our patient populations including those living with sickle cell disease, ulcerative colitis, Crohn’s disease, severe rheumatoid arthritis, lupus, multiple sclerosis and chronic kidney disease. Our mission is to improve health equity and enhance outcomes and quality of life by reducing avoidable emergency department and hospitalizations through comprehensive care coordination, home-based and telehealth services and innovative treatment models. We provide services on a national level in diverse communities, focusing on holistic, member-centered care that promotes independence and well-being for our members. improving outcomes for individuals living with chronic, inflammatory, and immune-related conditions."
Note there is a duplicated phrase at end: "improving outcomes for individuals living with chronic, inflammatory, and immune-related conditions." We'll keep it.
Position Overview text:
"The RN Case Manager (TOC / Travel Infusion / RPM / LTSS (Hybrid / Telephonic Role) supports Medicaid populations through proactive telephonic outreach, comprehensive assessments, and collaboration with interdisciplinary teams. This role helps ensure members receive appropriate case management and care coordination services that promote independence and quality of life. Position Overview The RN Case Manager (TOC / Travel Infusion / RPM / LTSS (Hybrid / Telephonic Role) is a hybrid role integrating telephonic case management and care coordination with travel-based home infusion therapy, TOC, RPM and LTSS responsibilities. In this role, the nurse manages a complex caseload
maybe, but instruction only mentions using for section headings (the listed ones). It doesn't forbid other headings, but to be safe we could keep them as
with bold? However we need to preserve structure. Could keep them as
but not prohibited. The instruction: "use for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule)." It implies that for those specific sections we should use h3. For other headings maybe we can use h4 or just keep as is. I'll keep subheadings as to differentiate.
We need to use - for any list of duties/requirements/benefits. So for responsibilities we should convert each duty into list items. The responsibilities are described in paragraphs with bullet-like sentences. We'll extract each duty as list items.
We need to preserve all substantive information, not invent or summarize away detail. So we need to keep details like specific conditions, tasks, etc.
Let's parse the posting.
Organizational Overview: first paragraph about Ponos Care. Then "improving outcomes for individuals living with chronic, inflammatory, and immune-related conditions." (maybe duplicate). We'll combine.
Position Overview: description of role.
Core Responsibilities: broken into sections with bullet-like paragraphs.
We'll create About the role section combining Organizational Overview and Position Overview (maybe summarizing but not losing detail). Must preserve all substantive information; we can't summarize away detail, but we can rephrase as long as we keep all info. The instruction: "Preserve ALL substantive information; do NOT invent or summarize away detail." So we cannot omit details, but we can rephrase? Summarizing away detail would be removing detail. Rephrasing while keeping all details is okay. We'll keep the info.
We'll produce
for prose.
For responsibilities, we need to convert each duty into list items. Let's extract duties:
From Core Responsibilities:
Patient Assessment & Care Planning:
- Conduct complete initial assessments of members via telephonic outreach or in-home visits as appropriate, including thorough evaluation of medical history, current health status, LTSS eligibility, functional abilities, caregiver support, and social needs.
- Use findings to identify risks and determine necessary interventions.
- Develop and implement personalized care plans addressing each member’s medical, behavioral health, social determinant, and (if needed) infusion therapy needs, in collaboration with the member, their family, and the interdisciplinary care team.
- Reassess member conditions continuously and modify care plans as needed to reflect changing needs and ensure effective care transitions (e.g., discharge planning after hospitalizations).
Clinical Care & Infusion Services:
- Provide direct clinical care as needed by administering infusion therapies and acute pain management treatments in members’ homes or community settings, performing IV line placements and medication administration in accordance with physician orders and established safety protocols.
- Monitor vital signs and member responses to treatments, making immediate adjustments or interventions as appropriate to ensure patient safety and comfort.
- Implement appropriate preventive and rehabilitative nursing procedures during in-person visits to support long-term health outcomes, including proactive care interventions and reinforcement of self-management skills for chronic condition management.
- Use of RPM (Remote patient monitoring) for high utilizers – monitoring feeds for triggers for clinical interventions.
- Educate members and their families on treatment plans, medications, disease management, and preventive care strategies to promote self-care and independence.
- Provide counseling and holistic wellness coaching as needed and serve as a member advocate to ensure that care is culturally competent and aligned with the member’s values and needs.
Case Management & Care Coordination:
- Coordinate clinical services and resources across the continuum of care by working closely with primary care providers, specialists, and community-based organizations to arrange appropriate treatments, referrals, and support services.
- Facilitate smooth transitions of care (e.g., post-hospital discharge follow-up) to maintain continuity of care.
- Conduct regular outreach to check on members’ progress, monitor their adherence to care plans, and proactively address barriers to care (e.g., scheduling issues, transportation, social challenges).
- Utilize remote patient monitoring tools and data to track health status, identify early signs of deterioration, and prompt timely interventions for chronic disease management.
- Triage and escalate high-risk findings or urgent clinical/behavioral health concerns per established protocols and triggers.
- Ensure timely communication and information sharing among all care team members, including the Primary Care Provider (PCP) and specialists, especially when significant changes occur in a member’s condition or care plan.
- Participate in interdisciplinary team meetings and case reviews to align on care strategies and optimize coordinated care delivery.
- Identify and connect members with relevant community-based programs, social services, and support organizations to address social determinants of health and augment the care plan.
- Follow up to ensure services are accessed and needs are met.
Documentation & Quality:
- Document all member assessments, care plans, outreach calls, visits, interventions, and outcomes promptly and accurately in the electronic health record (EHR/EMR) systems, in accordance with organizational policy and best practices.
- Ensure all documentation and care coordination activities meet organizational, audit, and regulatory standards (e.g., CMS, NCQA, HEDIS requirements), maintaining compliance with patient privacy (HIPAA) and safety protocols.
- Actively participate in quality improvement initiatives and monitor patient outcomes to identify opportunities for better care coordination and performance improvement.
Program Development & Innovation:
- Contribute to developing and refining case management and mobile infusion care policies, procedures, and workflows to enhance efficiency and operational excellence.
- Identify and implement innovative approaches to expand telehealth and home-based infusion services and improve access to care for underserved populations.
- Support Ponos Care’s value-based care goals by proposing and adopting best practices in care coordination and infusion therapy.
- Provide feedback to leadership on clinical outcomes and workflow improvements and assist in scaling successful care models to new regions or patient populations.
Regulatory & Compliance:
- Ensure full compliance with all relevant federal and state nursing regulations, CMS guidelines, and healthcare quality standards in daily practice.
- Strictly adhere to organizational policies, clinical protocols, and documentation requirements to maintain regulatory compliance.
- Maintain patient privacy and confidentiality in accordance with HIPAA and organizational standards.
- Follow all safety procedures for infusion therapy and medication administration to minimize risk and ensure patient safety.
Qualifications and Education:
- 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 relevant settings such as care management, population health, acute care, infusion therapy, hematology, pain management, or community health. Experience serving Medicaid or complex care populations is preferred. Knowledge of Long-Term Support Services is preferred.
- Certifications: Certified Case Manager (CCM) preferred. Additional specialty certifications such as ACLS (Advanced Cardiac Life Support), ONCC (Oncology Nursing), or CRNI (Certified Registered Nurse Infusion) are 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 is 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.
We need to output HTML fragment only.
We'll create sections:
About the role
Organizational overview paragraph(s) + Position overview paragraph(s). Combine.
We need to include all details from Organizational Overview and Position Overview.
Organizational Overview text:
"Ponos Care is a physician-led, value-based healthcare organization committed to delivering compassionate, holistic care to individuals with complex, chronic, inflammatory and immune-related conditions. We integrate social, mental, physical and economic solutions to address the unique needs of our patient populations including those living with sickle cell disease, ulcerative colitis, Crohn’s disease, severe rheumatoid arthritis, lupus, multiple sclerosis and chronic kidney disease. Our mission is to improve health equity and enhance outcomes and quality of life by reducing avoidable emergency department and hospitalizations through comprehensive care coordination, home-based and telehealth services and innovative treatment models. We provide services on a national level in diverse communities, focusing on holistic, member-centered care that promotes independence and well-being for our members. improving outcomes for individuals living with chronic, inflammatory, and immune-related conditions."
Note there is a duplicated phrase at end: "improving outcomes for individuals living with chronic, inflammatory, and immune-related conditions." We'll keep it.
Position Overview text:
"The RN Case Manager (TOC / Travel Infusion / RPM / LTSS (Hybrid / Telephonic Role) supports Medicaid populations through proactive telephonic outreach, comprehensive assessments, and collaboration with interdisciplinary teams. This role helps ensure members receive appropriate case management and care coordination services that promote independence and quality of life. Position Overview The RN Case Manager (TOC / Travel Infusion / RPM / LTSS (Hybrid / Telephonic Role) is a hybrid role integrating telephonic case management and care coordination with travel-based home infusion therapy, TOC, RPM and LTSS responsibilities. In this role, the nurse manages a complex caseload
to differentiate.
We need to use - for any list of duties/requirements/benefits. So for responsibilities we should convert each duty into list items. The responsibilities are described in paragraphs with bullet-like sentences. We'll extract each duty as list items.
We need to preserve all substantive information, not invent or summarize away detail. So we need to keep details like specific conditions, tasks, etc.
Let's parse the posting.
Organizational Overview: first paragraph about Ponos Care. Then "improving outcomes for individuals living with chronic, inflammatory, and immune-related conditions." (maybe duplicate). We'll combine.
Position Overview: description of role.
Core Responsibilities: broken into sections with bullet-like paragraphs.
We'll create About the role section combining Organizational Overview and Position Overview (maybe summarizing but not losing detail). Must preserve all substantive information; we can't summarize away detail, but we can rephrase as long as we keep all info. The instruction: "Preserve ALL substantive information; do NOT invent or summarize away detail." So we cannot omit details, but we can rephrase? Summarizing away detail would be removing detail. Rephrasing while keeping all details is okay. We'll keep the info.
We'll produce
for prose.
For responsibilities, we need to convert each duty into list items. Let's extract duties:
From Core Responsibilities:
Patient Assessment & Care Planning:
- Conduct complete initial assessments of members via telephonic outreach or in-home visits as appropriate, including thorough evaluation of medical history, current health status, LTSS eligibility, functional abilities, caregiver support, and social needs.
- Use findings to identify risks and determine necessary interventions.
- Develop and implement personalized care plans addressing each member’s medical, behavioral health, social determinant, and (if needed) infusion therapy needs, in collaboration with the member, their family, and the interdisciplinary care team.
- Reassess member conditions continuously and modify care plans as needed to reflect changing needs and ensure effective care transitions (e.g., discharge planning after hospitalizations).
Clinical Care & Infusion Services:
- Provide direct clinical care as needed by administering infusion therapies and acute pain management treatments in members’ homes or community settings, performing IV line placements and medication administration in accordance with physician orders and established safety protocols.
- Monitor vital signs and member responses to treatments, making immediate adjustments or interventions as appropriate to ensure patient safety and comfort.
- Implement appropriate preventive and rehabilitative nursing procedures during in-person visits to support long-term health outcomes, including proactive care interventions and reinforcement of self-management skills for chronic condition management.
- Use of RPM (Remote patient monitoring) for high utilizers – monitoring feeds for triggers for clinical interventions.
- Educate members and their families on treatment plans, medications, disease management, and preventive care strategies to promote self-care and independence.
- Provide counseling and holistic wellness coaching as needed and serve as a member advocate to ensure that care is culturally competent and aligned with the member’s values and needs.
Case Management & Care Coordination:
- Coordinate clinical services and resources across the continuum of care by working closely with primary care providers, specialists, and community-based organizations to arrange appropriate treatments, referrals, and support services.
- Facilitate smooth transitions of care (e.g., post-hospital discharge follow-up) to maintain continuity of care.
- Conduct regular outreach to check on members’ progress, monitor their adherence to care plans, and proactively address barriers to care (e.g., scheduling issues, transportation, social challenges).
- Utilize remote patient monitoring tools and data to track health status, identify early signs of deterioration, and prompt timely interventions for chronic disease management.
- Triage and escalate high-risk findings or urgent clinical/behavioral health concerns per established protocols and triggers.
- Ensure timely communication and information sharing among all care team members, including the Primary Care Provider (PCP) and specialists, especially when significant changes occur in a member’s condition or care plan.
- Participate in interdisciplinary team meetings and case reviews to align on care strategies and optimize coordinated care delivery.
- Identify and connect members with relevant community-based programs, social services, and support organizations to address social determinants of health and augment the care plan.
- Follow up to ensure services are accessed and needs are met.
Documentation & Quality:
- Document all member assessments, care plans, outreach calls, visits, interventions, and outcomes promptly and accurately in the electronic health record (EHR/EMR) systems, in accordance with organizational policy and best practices.
- Ensure all documentation and care coordination activities meet organizational, audit, and regulatory standards (e.g., CMS, NCQA, HEDIS requirements), maintaining compliance with patient privacy (HIPAA) and safety protocols.
- Actively participate in quality improvement initiatives and monitor patient outcomes to identify opportunities for better care coordination and performance improvement.
Program Development & Innovation:
- Contribute to developing and refining case management and mobile infusion care policies, procedures, and workflows to enhance efficiency and operational excellence.
- Identify and implement innovative approaches to expand telehealth and home-based infusion services and improve access to care for underserved populations.
- Support Ponos Care’s value-based care goals by proposing and adopting best practices in care coordination and infusion therapy.
- Provide feedback to leadership on clinical outcomes and workflow improvements and assist in scaling successful care models to new regions or patient populations.
Regulatory & Compliance:
- Ensure full compliance with all relevant federal and state nursing regulations, CMS guidelines, and healthcare quality standards in daily practice.
- Strictly adhere to organizational policies, clinical protocols, and documentation requirements to maintain regulatory compliance.
- Maintain patient privacy and confidentiality in accordance with HIPAA and organizational standards.
- Follow all safety procedures for infusion therapy and medication administration to minimize risk and ensure patient safety.
Qualifications and Education:
- 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 relevant settings such as care management, population health, acute care, infusion therapy, hematology, pain management, or community health. Experience serving Medicaid or complex care populations is preferred. Knowledge of Long-Term Support Services is preferred.
- Certifications: Certified Case Manager (CCM) preferred. Additional specialty certifications such as ACLS (Advanced Cardiac Life Support), ONCC (Oncology Nursing), or CRNI (Certified Registered Nurse Infusion) are 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 is 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.
We need to output HTML fragment only.
We'll create sections:
About the role
Organizational overview paragraph(s) + Position overview paragraph(s). Combine.
We need to include all details from Organizational Overview and Position Overview.
Organizational Overview text:
"Ponos Care is a physician-led, value-based healthcare organization committed to delivering compassionate, holistic care to individuals with complex, chronic, inflammatory and immune-related conditions. We integrate social, mental, physical and economic solutions to address the unique needs of our patient populations including those living with sickle cell disease, ulcerative colitis, Crohn’s disease, severe rheumatoid arthritis, lupus, multiple sclerosis and chronic kidney disease. Our mission is to improve health equity and enhance outcomes and quality of life by reducing avoidable emergency department and hospitalizations through comprehensive care coordination, home-based and telehealth services and innovative treatment models. We provide services on a national level in diverse communities, focusing on holistic, member-centered care that promotes independence and well-being for our members. improving outcomes for individuals living with chronic, inflammatory, and immune-related conditions."
Note there is a duplicated phrase at end: "improving outcomes for individuals living with chronic, inflammatory, and immune-related conditions." We'll keep it.
Position Overview text:
"The RN Case Manager (TOC / Travel Infusion / RPM / LTSS (Hybrid / Telephonic Role) supports Medicaid populations through proactive telephonic outreach, comprehensive assessments, and collaboration with interdisciplinary teams. This role helps ensure members receive appropriate case management and care coordination services that promote independence and quality of life. Position Overview The RN Case Manager (TOC / Travel Infusion / RPM / LTSS (Hybrid / Telephonic Role) is a hybrid role integrating telephonic case management and care coordination with travel-based home infusion therapy, TOC, RPM and LTSS responsibilities. In this role, the nurse manages a complex caseload
for prose. For responsibilities, we need to convert each duty into list items. Let's extract duties: From Core Responsibilities: Patient Assessment & Care Planning: - Conduct complete initial assessments of members via telephonic outreach or in-home visits as appropriate, including thorough evaluation of medical history, current health status, LTSS eligibility, functional abilities, caregiver support, and social needs. - Use findings to identify risks and determine necessary interventions. - Develop and implement personalized care plans addressing each member’s medical, behavioral health, social determinant, and (if needed) infusion therapy needs, in collaboration with the member, their family, and the interdisciplinary care team. - Reassess member conditions continuously and modify care plans as needed to reflect changing needs and ensure effective care transitions (e.g., discharge planning after hospitalizations). Clinical Care & Infusion Services: - Provide direct clinical care as needed by administering infusion therapies and acute pain management treatments in members’ homes or community settings, performing IV line placements and medication administration in accordance with physician orders and established safety protocols. - Monitor vital signs and member responses to treatments, making immediate adjustments or interventions as appropriate to ensure patient safety and comfort. - Implement appropriate preventive and rehabilitative nursing procedures during in-person visits to support long-term health outcomes, including proactive care interventions and reinforcement of self-management skills for chronic condition management. - Use of RPM (Remote patient monitoring) for high utilizers – monitoring feeds for triggers for clinical interventions. - Educate members and their families on treatment plans, medications, disease management, and preventive care strategies to promote self-care and independence. - Provide counseling and holistic wellness coaching as needed and serve as a member advocate to ensure that care is culturally competent and aligned with the member’s values and needs. Case Management & Care Coordination: - Coordinate clinical services and resources across the continuum of care by working closely with primary care providers, specialists, and community-based organizations to arrange appropriate treatments, referrals, and support services. - Facilitate smooth transitions of care (e.g., post-hospital discharge follow-up) to maintain continuity of care. - Conduct regular outreach to check on members’ progress, monitor their adherence to care plans, and proactively address barriers to care (e.g., scheduling issues, transportation, social challenges). - Utilize remote patient monitoring tools and data to track health status, identify early signs of deterioration, and prompt timely interventions for chronic disease management. - Triage and escalate high-risk findings or urgent clinical/behavioral health concerns per established protocols and triggers. - Ensure timely communication and information sharing among all care team members, including the Primary Care Provider (PCP) and specialists, especially when significant changes occur in a member’s condition or care plan. - Participate in interdisciplinary team meetings and case reviews to align on care strategies and optimize coordinated care delivery. - Identify and connect members with relevant community-based programs, social services, and support organizations to address social determinants of health and augment the care plan. - Follow up to ensure services are accessed and needs are met. Documentation & Quality: - Document all member assessments, care plans, outreach calls, visits, interventions, and outcomes promptly and accurately in the electronic health record (EHR/EMR) systems, in accordance with organizational policy and best practices. - Ensure all documentation and care coordination activities meet organizational, audit, and regulatory standards (e.g., CMS, NCQA, HEDIS requirements), maintaining compliance with patient privacy (HIPAA) and safety protocols. - Actively participate in quality improvement initiatives and monitor patient outcomes to identify opportunities for better care coordination and performance improvement. Program Development & Innovation: - Contribute to developing and refining case management and mobile infusion care policies, procedures, and workflows to enhance efficiency and operational excellence. - Identify and implement innovative approaches to expand telehealth and home-based infusion services and improve access to care for underserved populations. - Support Ponos Care’s value-based care goals by proposing and adopting best practices in care coordination and infusion therapy. - Provide feedback to leadership on clinical outcomes and workflow improvements and assist in scaling successful care models to new regions or patient populations. Regulatory & Compliance: - Ensure full compliance with all relevant federal and state nursing regulations, CMS guidelines, and healthcare quality standards in daily practice. - Strictly adhere to organizational policies, clinical protocols, and documentation requirements to maintain regulatory compliance. - Maintain patient privacy and confidentiality in accordance with HIPAA and organizational standards. - Follow all safety procedures for infusion therapy and medication administration to minimize risk and ensure patient safety. Qualifications and Education: - 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 relevant settings such as care management, population health, acute care, infusion therapy, hematology, pain management, or community health. Experience serving Medicaid or complex care populations is preferred. Knowledge of Long-Term Support Services is preferred. - Certifications: Certified Case Manager (CCM) preferred. Additional specialty certifications such as ACLS (Advanced Cardiac Life Support), ONCC (Oncology Nursing), or CRNI (Certified Registered Nurse Infusion) are 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 is 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. We need to output HTML fragment only. We'll create sections:
About the role
Organizational overview paragraph(s) + Position overview paragraph(s). Combine. We need to include all details from Organizational Overview and Position Overview. Organizational Overview text: "Ponos Care is a physician-led, value-based healthcare organization committed to delivering compassionate, holistic care to individuals with complex, chronic, inflammatory and immune-related conditions. We integrate social, mental, physical and economic solutions to address the unique needs of our patient populations including those living with sickle cell disease, ulcerative colitis, Crohn’s disease, severe rheumatoid arthritis, lupus, multiple sclerosis and chronic kidney disease. Our mission is to improve health equity and enhance outcomes and quality of life by reducing avoidable emergency department and hospitalizations through comprehensive care coordination, home-based and telehealth services and innovative treatment models. We provide services on a national level in diverse communities, focusing on holistic, member-centered care that promotes independence and well-being for our members. improving outcomes for individuals living with chronic, inflammatory, and immune-related conditions." Note there is a duplicated phrase at end: "improving outcomes for individuals living with chronic, inflammatory, and immune-related conditions." We'll keep it. Position Overview text: "The RN Case Manager (TOC / Travel Infusion / RPM / LTSS (Hybrid / Telephonic Role) supports Medicaid populations through proactive telephonic outreach, comprehensive assessments, and collaboration with interdisciplinary teams. This role helps ensure members receive appropriate case management and care coordination services that promote independence and quality of life. Position Overview The RN Case Manager (TOC / Travel Infusion / RPM / LTSS (Hybrid / Telephonic Role) is a hybrid role integrating telephonic case management and care coordination with travel-based home infusion therapy, TOC, RPM and LTSS responsibilities. In this role, the nurse manages a complex caseload