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.

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, individualized care planning, and coordination of medical, behavioral health, and social support services across multiple states. The role requires travel to patients’ homes for infusion therapies, acute pain management, and monitoring, while ensuring continuity of care and reducing avoidable hospital readmissions and emergency department utilization.

Responsibilities

• Patient Assessment & Care Planning
  • Conduct comprehensive initial assessments via telephonic outreach or in-home visits, evaluating medical history, health status, LTSS eligibility, functional abilities, caregiver support, and social needs.
  • Develop and implement personalized care plans addressing medical, behavioral health, social determinants, and infusion therapy needs in collaboration with the member, family, and interdisciplinary team.
  • Continuously reassess and modify care plans to reflect changing needs and ensure effective care transitions (e.g., post-hospitalization discharge planning).
• 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 to treatments, making immediate adjustments or interventions to ensure safety and comfort.
  • Implement preventive and rehabilitative nursing procedures during in-person visits to support long-term health outcomes.
  • Utilize Remote Patient Monitoring (RPM) for high utilizers, monitoring data for clinical intervention triggers.
• Member Education & Advocacy
  • Educate members and families on treatment plans, medications, disease management, and preventive care strategies to promote self-care and independence.
  • Provide holistic wellness coaching and serve as a member advocate to ensure culturally competent care aligned with the member’s values and needs.
• Case Management & Care Coordination
  • Coordinate clinical services and resources across the continuum of care, collaborating with primary care providers, specialists, and community-based organizations.
  • Facilitate smooth transitions of care (e.g., post-hospital discharge follow-up) to maintain continuity.
  • Conduct regular outreach to monitor member progress, adherence to care plans, and address barriers to care (e.g., scheduling, transportation, social challenges).
  • Utilize RPM tools to track health status, identify early signs of deterioration, and prompt timely interventions.
  • Triage and escalate high-risk findings or urgent clinical/behavioral health concerns per established protocols.
• Interdisciplinary Collaboration and Communication
  • Ensure timely communication and information sharing among care team members, including Primary Care Providers (PCPs) and specialists.
  • Participate in interdisciplinary team meetings and case reviews to align on care strategies and optimize coordinated care delivery.
• Community Resources & Referrals
  • Identify and connect members with community-based programs, social services, and support organizations to address social determinants of health.
  • 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 EHR/EMR systems.
  • Ensure documentation and care coordination activities meet organizational, audit, and regulatory standards (e.g., CMS, NCQA, HEDIS).
  • 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.
• Program Development & Innovation
  • Contribute to developing and refining case management and mobile infusion care policies, procedures, and workflows to enhance efficiency.
  • Identify and implement innovative approaches to expand telehealth and home-based infusion services for underserved populations.
  • Support 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 to scale successful care models.
• Regulatory & Compliance
  • Ensure full compliance with federal and state nursing regulations, CMS guidelines, and healthcare quality standards.
  • 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.

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 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, 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.