New Jersey-RN Case Manager

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Full Time Non-Management IC Atlantic, NJ, US

6 days ago Requisition

Salary Range: $45.00 To $60.00 Hourly

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 and chronic kidney disease.

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 / Travel Infusion / RPM / LTSS (Hybrid / Telephonic Role) supports Medicaid populations through proactive 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 / Travel Infusion / RPM / LTSS (Hybrid / Telephonic Role) is a hybrid role integrating telephonic case management and care coordination with travel-based home infusion therapy, 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/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, as the RN adapts between remote case management and mobile healthcare delivery, 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, and (if needed) infusion therapy needs, in collaboration…