RN - Telephonic Case Manager
About The Position
Ponos Care is a physician-led, value-based healthcare organization committed to improving outcomes for individuals living with chronic, inflammatory, and immune-related conditions. Through compassionate care delivery, innovative treatment models, and data-informed clinical practices, Ponos Care focuses on improving health equity, enhancing patient outcomes, and reducing avoidable hospitalizations. The RN Telephonic Case Manager 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.
Requirements
- Active multistate Registered Nurse (RN) license required
- Minimum 2+ years of experience in care management, case management, or population health
- Experience using electronic health record (EHR) systems
- Ability to manage complex caseloads in a remote work environment
- Strong communication and care coordination skills
Nice To Haves
- CCM certification preferred
- Experience supporting Medicaid populations or complex care environments preferred
- Knowledge of Long-Term Services and Supports (LTSS) programs
Responsibilities
- Complete comprehensive telephonic assessments for members
- Develop individualized care plans addressing medical, behavioral health, and social support needs
- Coordinate clinical services with providers, specialists, and community-based organizations
- Facilitate continuity of care following hospital discharge and other care transitions
- Conduct ongoing outreach to monitor progress, reassess needs, and update care plans as indicated
- Partner with interdisciplinary teams to support eligibility reviews and service planning
- Review clinical documentation and submit required information to support continuity of care
- Coordinate services and referrals to community-based programs to meet member needs
- Track engagement and adherence, and address barriers
- Ensure timely communication and escalation between the care team and PCP and specialists
- Triage and escalate high-risk findings per protocol, triggers and alerts and urgent clinical or behavioral health concerns
- Support implementation and optimization of care management programs to improve outcomes and reduce avoidable utilization
- Document assessments, outreach, care plans, and interventions accurately in the electronic health record (EHR)
- Ensure documentation meets organizational policies and regulatory and audit standards
- Identify and help close HEDIS care gaps and other quality performance measures
- Participate in quality improvement activities to strengthen care coordination outcomes
- Collaborate with physicians, nurses, social workers, and other care team members to coordinate care
- Align services and resources across medical, behavioral health, and social needs
- Communicate member priorities, barriers, and care plan updates to the interdisciplinary team
- Contribute to the development and maintenance of policies, procedures, and workflows for case management programs
- Identify opportunities to streamline care coordination, improve member experience, reduce avoidable utilization, and advance value-based care goals
- Participate in continuous improvement initiatives aligned with organizational goals and quality performance
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
