Organizational Overview

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, chronic kidney disease and other chronic diseases. Our mission is to improve health equity and enhance outcomes and quality of life by reducing avoidable emergency department and hospitalizations through comprehensive care coordination, home-based and telehealth services and innovative treatment models. We provide services on a national level in diverse communities, focusing on holistic, member-centered care that promotes independence and well-being for our members. improving outcomes for individuals living with chronic, inflammatory, and immune-related conditions.

The RN Case Manager (TOC / RPM / LTSS (Hybrid - Home Visits, Telehealth, Telephonic) supports Medicaid populations through proactive home visits, telehealth and telephonic outreach, comprehensive assessments, and collaboration with interdisciplinary teams. This role helps ensure members receive appropriate case management and care coordination services that promote independence and quality of life.

Position Overview

The RN Case Manager (TOC/ RPM / LTSS (Home Visits, Telehealth, Telephonic Role) is a hybrid role integrating telephonic case management and care coordination with travel-based home visits, TOC, RPM and LTSS responsibilities. In this role, 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 include proactive telephonic outreach, comprehensive assessments (telephonic and in-home), individualized care planning, and coordination of medical, behavioral health, and social support services for members across multiple states. The nurse collaborates 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/STARS) and member satisfaction. As needed, this role travels to patients’ homes to perform comprehensive home assessments. 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, as the RN adapts between remote case management home based environment, ensuring high-quality, patient-centered care in every setting. This role supports value-based care initiatives and ensures care management activities meet applicable regulatory, quality, and documentation standards, including NCQA and HEDIS requirements.

Core Responsibilities

Patient Assessment & Care Planning

Comprehensive Assessments: Conduct complete initial assessments of members via telephonic outreach or in-home visits as appropriate, including thorough evaluation of medical history, current health status, LTSS eligibility, functional abilities, caregiver support, and social needs. Use findings to identify risks and determine necessary interventions.

Individualized Care Plans: Develop and implement personalized care plans addressing each member’s medical, behavioral health, social determinant, in collaboration with the member, their family, and the interdisciplinary care team. Reassess member conditions continuously and modify care plans as needed to reflect changing needs and ensure effective care transitions (e.g., discharge planning after hospitalizations).

Clinical Care

Preventive & Rehabilitative Nursing: Implement appropriate 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 for chronic condition management. Use of RPM (Remote patient monitoring) for high utilizers – monitoring feeds for triggers for 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 as needed and serve as a member advocate to ensure that care is culturally competent and aligned with the member’s values and needs.

Case Management & Care Coordination

Service Coordination: Coordinate clinical services and resources across the continuum of care by working closely with primary care providers, specialists, and community-based organizations to arrange appropriate treatments, referrals, and support services. Facilitate smooth transitions of care (e.g., post-hospital discharge follow-up) to maintain continuity of care.

Ongoing Monitoring & Support: Conduct regular outreach to check members’ progress, monitor their 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 for chronic disease management. Triage and escalate high-risk findings or urgent clinical/behavioral health concerns per established protocols and triggers.

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 and augment the care plan. Follow up to ensure services are accessed and needs are met.

Documentation & Quality

Accurate Record-Keeping: Document all member assessments, care plans, outreach calls, visits, interventions, and outcomes promptly and accurately in the electronic health record (EHR/EMR) systems, in accordance with organizational policy and best practices.

Quality Standards: 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

Policy & Workflow Improvement: Contribute to developing and refining case management and 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.

Value-Based Care & Growth: Support Ponos Care’s value-based care goals by proposing and adopting best practices in care coordination. 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

Regulatory Adherence: 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.

Privacy & Safety:

Maintain patient privacy and confidentiality in accordance with HIPAA and organizational standards.

Qualifications and Education

Education & Licensure: Bachelor’s degree in nursing (BSN) or equivalent required. Active Illinois Registered Nurse (RN) license 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, hematology, pain management, or community health.
Experience serving Medicaid or complex care populations is preferred. Knowledge of Long-Term Support Services is preferred.

Certifications: Certified Case Manager (CCM) preferred. Additional specialty certifications such as ACLS (Advanced Cardiac Life Support), ONCC (Oncology Nursing) 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.

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.
Must reside in Illinois

EEO Statement

We are an Equal Opportunity Employer and are committed to fostering an inclusive and diverse workplace. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy, sexual orientation, gender identity or expression), national origin, age, disability, genetic information, veteran status, or any other protected characteristic in accordance with applicable federal, state, and local laws.

We believe inclusion strengthens our organization and enhances our ability to serve members and communities nationwide. We are committed to providing reasonable accommodation for qualified individuals with disabilities throughout the recruitment and employment process.

PONOS MGMT INC

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