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

The RN Case Manager (Hybrid / Telephonic Role) 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 (TOC), Remote Patient Monitoring (RPM), and Long-Term Services and Supports (LTSS). The nurse manages a complex caseload of members, providing both remote support and in-person clinical care to achieve optimal health outcomes.

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 personalized care plans addressing medical, behavioral health, social determinant, 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, performing IV line placements and medication administration in accordance with 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.
  • Use Remote Patient Monitoring (RPM) for high utilizers, monitoring feeds for triggers requiring clinical interventions.
• Member Education & Advocacy
  • 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, ensuring 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 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 members’ progress, 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.
  • 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 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.
• Community Resources & Referrals
  • Identify and connect members with relevant 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 electronic health record (EHR/EMR) systems.
  • 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.
  • 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 is preferred.
  • Knowledge of Long-Term Support Services (LTSS) 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.
  • 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.