LTSS Telephonic Case Manager - Remote Patient Monitoring (RPM)

Organizational Overview

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 LTSS Telephonic Case Manager supports Medicaid populations through proactive telephonic outreach, comprehensive assessments, and collaboration with interdisciplinary teams. This role helps ensure members receive appropriate LTSS and RPM services that promote independence and quality of life.

Position Overview

The LTSS Telephonic Case Manager manages complex member caseloads requiring Long-Term Services and Supports (LTSS) and Remote Patient Monitoring (RPM). The role completes telephonic assessments, develops individualized care plans, and coordinates services addressing medical, behavioral health, and social determinants of health needs.

The Case Manager partners with interdisciplinary teams, providers, and community organizations to ensure continuity of care, support safe transitions, reduce avoidable hospitalizations, and improve member outcomes.

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

Care Management & Coordination

• Complete comprehensive telephonic assessments for members receiving or applying for LTSS services


• Develop individualized care plans addressing medical, behavioral health, and social support needs


• Coordinate LTSS and 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

LTSS Program Support

• Coordinate LTSS applications and documentation requirements in partnership with the realignment team


• Partner with interdisciplinary teams to support eligibility reviews and service planning


• Review clinical documentation and submit required information to support LTSS determinations


• Coordinate waiver services and referrals to community-based programs to meet member needs

Remote Patient Monitoring (RPM) Coordination

• Partner with RPM vendors to enroll eligible members and maintain effective monitoring workflows


• Track RPM engagement and adherence, and address barriers to device use and data capture


• Ensure timely communication and escalation between the care team and RPM partners for alerts and clinical concerns


• Triage and escalate high-risk findings per protocol, including RPM alerts and urgent clinical or behavioral health concerns


• Support implementation and optimization of RPM programs to improve outcomes and reduce avoidable utilization


• Train the Feet on the Street Team on RPM device setup, unboxing, and basic troubleshooting

Documentation & Quality Reporting

• 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

Interdisciplinary Collaboration

• 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


• Promote integrated care coordination across LTSS, medical management, and RPM services

Program Development Support

• 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

Qualifications and Education

• Active multistate Registered Nurse (RN) license required


• CCM certification preferred


• Minimum 2 years of experience in care management, case management, or population health


• Experience supporting Medicaid populations or complex care environments preferred


• Knowledge of Long-Term Services and Supports (LTSS) programs


• Experience using electronic health record (EHR) systems


• Ability to manage complex caseloads in a remote work environment


• Strong communication and care coordination skills

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.