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. We integrate social, mental, physical and economic solutions for patients 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 visits and hospitalizations through comprehensive care coordination, home-based and telehealth services, and innovative treatment models.

The RN Case Manager (TOC / Travel Infusion / RPM / LTSS) supports Medicaid populations through proactive telephonic outreach, comprehensive assessments, and collaboration with interdisciplinary teams. This hybrid role integrates telephonic case management and care coordination with travel-based home infusion therapy, TOC, RPM and LTSS responsibilities. The nurse manages a complex caseload of members and provides both remote support and in-person clinical care as needed to achieve optimal health outcomes.

Key duties

• Conduct complete initial assessments of members via telephonic outreach or in-home visits, evaluating 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.
• 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 response.
• Provide education to members and families on treatment plans, medications, disease management, preventive care, and self-management strategies.
• Coordinate clinical services and resources across the continuum of care by working with primary care providers, specialists, and community-based organizations.
• Conduct regular outreach to monitor adherence to care plans, address barriers to care, and utilize remote patient monitoring tools to track health status and prompt timely interventions.
• Travel to patients’ homes to perform infusion therapies and acute pain management, including IV-line placement, administration of intravenous treatments, and monitoring of patient response and vital signs during and after infusions.
• 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.

Qualifications

• 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.
• 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 is preferred.
• Knowledge of Long-Term Support Services is preferred.
• Certified Case Manager (CCM) preferred.
• Additional specialty certifications such as ACLS, ONCC, or CRNI are highly desirable.
• 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.
• 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.