VA - RN Case Manager (Tidewater Area)

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 visits and hospitalizations through comprehensive care coordination, home-based and telehealth services, and innovative treatment models.

About the Role

This hybrid role integrates telephonic case management and care coordination with travel-based home infusion therapy, Transitions of Care (TOC), Remote Patient Monitoring (RPM), and Long-Term Support Services (LTSS). The RN Case Manager manages a complex caseload of Medicaid members, providing both remote support and in-person clinical care to achieve optimal health outcomes. Key responsibilities include proactive telephonic outreach, comprehensive assessments (telephonic and in-home), individualized care planning, and coordination of medical, behavioral health, and social support services across multiple states. The role involves collaboration with interdisciplinary teams, providers, caregivers, and community resources to ensure continuity of care and safe transitions, with the goal of reducing avoidable hospital readmissions and emergency department utilization while enhancing quality metrics (HEDIS/STAR) and member satisfaction.

As needed, this role travels 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. The RN provides education to members and families on treatment plans, medications, preventive care, and self-management strategies, reinforcing disease management and holistic wellness principles. Success in this role requires flexibility, clinical expertise, and a commitment to health equity, adapting between remote case management and mobile healthcare delivery.

Responsibilities

• Patient Assessment & Care Planning
  • Conduct comprehensive 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 determinants, and infusion therapy needs in collaboration with the member, their family, and the interdisciplinary care team.
  • Continuously reassess member conditions and modify care plans to reflect changing needs, ensuring 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 placements and medication administration per physician orders and safety protocols.
  • Monitor vital signs and member responses to treatments, making immediate adjustments or interventions to ensure patient safety and comfort.
  • Implement 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.
  • Utilize Remote Patient Monitoring (RPM) for high-utilization members, monitoring data for clinical intervention triggers.
  • Educate members and families on treatment plans, medications, disease management, and preventive care strategies to promote self-care and independence.
  • Provide counseling, holistic wellness coaching, and advocacy to ensure culturally competent care aligned with the member’s values and needs.
• Case Management & Care Coordination
  • Coordinate clinical services and resources across the care continuum 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.
  • Conduct regular outreach to monitor members’ progress, adherence to care plans, and proactively address barriers to care (e.g., scheduling, transportation, social challenges).
  • Utilize remote patient monitoring tools 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.
  • Ensure timely communication and information sharing among care team members, including Primary Care Providers (PCPs) and specialists, especially during significant changes 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 community-based programs, social services, and support organizations to address social determinants of health and augment care plans.
  • 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 electronic health record (EHR/EMR) systems.
  • Ensure documentation and care coordination activities meet organizational, audit, and regulatory standards (e.g., CMS, NCQA, HEDIS requirements) and comply 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.

Requirements

• 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 preferred.
  • Knowledge of Long-Term Support Services (LTSS) 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 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.