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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, and (if needed) infusion therapy needs, 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 & Infusion Services Infusion Therapy Administration:

Provide direct clinical care as needed by administering 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 established safety protocols. Monitor vital signs and member responses to treatments, making immediate adjustments or interventions as appropriate to ensure patient safety and comfort.

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 on 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 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.

Value-Based Care & Growth:

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 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. Follow all safety procedures for infusion therapy and medication administration to minimize risk and ensure patient safety.

Qualifications and Education 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 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.

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. 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. 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Find & Apply For Registered Nurse Jobs in Newport, Maryland

VA - RN Case Manager (Tidewater Area)