Illinois-RN Case Manager

PONOS MGMT INC•Chicago, IL

7d•$80,000 - $120,000•Hybrid

About The Position

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.

Requirements

Bachelor’s degree in nursing (BSN) or equivalent required.
Active Illinois Registered Nurse (RN) license of practice.
CPR/BLS certification required.
Minimum 2+ years of clinical nursing experience in relevant settings such as care management, population health, acute care, hematology, pain management, or community health.
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.
Must reside in Illinois

Nice To Haves

Experience serving Medicaid or complex care populations is preferred.
Knowledge of Long-Term Support Services is preferred.
Certified Case Manager (CCM) preferred.
Additional specialty certifications such as ACLS (Advanced Cardiac Life Support), ONCC (Oncology Nursing) are highly desirable.
Expertise with electronic health record systems and remote patient monitoring technology is preferred.
Bilingual proficiency is a plus.

Responsibilities

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