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, transitions of care, remote patient monitoring, and long-term services and supports. The nurse manages a complex caseload, provides remote and in-person clinical care, and partners with providers, caregivers, and community resources to ensure continuity of care and safe transitions, aiming to reduce avoidable hospital readmissions and emergency department utilization while improving HEDIS/STAR quality metrics and member satisfaction.

Responsibilities

• Patient Assessment & Care Planning
  • 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 individualized care plans addressing medical, behavioral health, social determinant, and infusion therapy needs in collaboration with the member, family, and interdisciplinary team.
  • Reassess member conditions continuously and modify care plans to reflect changing needs and ensure effective care transitions (e.g., discharge planning after hospitalizations).
• Clinical Care & Infusion Services
  • Administer infusion therapies and acute pain management treatments in members’ homes or community settings, including IV line placement and medication administration per physician orders and safety protocols.
  • Monitor vital signs and member responses during and after infusions, making immediate adjustments or interventions as needed to ensure patient safety and comfort.
  • Implement preventive and rehabilitative nursing procedures during in-person visits to support long-term health outcomes and reinforce self-management skills.
  • Use remote patient monitoring for high utilizers, monitoring feeds for triggers requiring clinical interventions.
• Member Education & Advocacy
  • Educate members and families on treatment plans, medications, disease management, and preventive care strategies to promote self-care and independence.
  • Provide counseling and holistic wellness coaching and serve as a member advocate to ensure culturally competent, values-aligned care.
• Case Management & Care Coordination
  • Coordinate clinical services and resources across the continuum of care by collaborating with primary care providers, specialists, and community-based organizations to arrange 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 monitor adherence to care plans, proactively address barriers to care, and utilize remote monitoring data to track health status and prompt timely interventions.
  • Triage and escalate high-risk findings or urgent clinical/behavioral health concerns per established protocols.
  • Ensure timely communication and information sharing among care team members, 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.
  • Identify and connect members with community-based programs, social services, and support organizations 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 in accordance with organizational policy and best practices.
  • Ensure documentation and care coordination activities meet organizational, audit, and regulatory standards (e.g., CMS, NCQA, HEDIS) and maintain compliance with patient privacy (HIPAA) and safety protocols.
  • 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 value-based care goals by proposing and adopting best practices in care coordination and infusion therapy, and assist in scaling successful care models to new regions or patient populations.
• Regulatory & Compliance
  • Ensure full compliance with federal and state nursing regulations, CMS guidelines, and healthcare quality standards in daily practice.
  • 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

• 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.