Nurse Practitioner

Job Description

Organizational Overview

Ponos Management, LLC specializes in providing compassionate value-based care through a physician-driven, home- and mobile-based model. Our comprehensive approach integrates social, mental, physical, and economic solutions, addressing the unique needs of patients with chronic conditions such as sickle cell disease, ulcerative colitis, Crohn's disease, and severe rheumatoid arthritis.

Our mission is to reduce emergency room visits and improve the quality of life for our patients through comprehensive, holistic coordinated care. We provide services currently on a national level.

Position Overview

The Nurse Practitioner (NP) will have oversight of a unique membership population requiring specialized chronic disease management. This position requires clinical expertise supporting patients with hematology, rheumatology, and gastrointestinal conditions.

The Nurse Practitioner serves as a key clinical leader within the Ponos Care model, delivering patient centered care through a hybrid environment that includes telehealth services and in home patient visits within a 30-mile radius of Richmond, Virginia.

The NP collaborates closely with physicians, social workers, nurses, and care coordinators to ensure patients receive comprehensive and coordinated care.

Core Responsibilities

Patient Care

• Provide comprehensive clinical care to patients with conditions such as Sickle Cell Disease, Crohn’s Disease, and severe rheumatoid arthritis.
• Conduct comprehensive health assessments including physical examinations, medical history reviews, and diagnostic evaluations.
• Develop and implement individualized care plans for chronic disease management.
• Conduct telehealth consultations and in-house visits to evaluate patient progress and clinical outcomes.
• Prescribe medications and treatment plans in accordance with state licensing requirements.
• Provide ongoing monitoring and follow up care to ensure treatment effectiveness.

Patient Education

• Educate patients and their families on disease management, treatment plans, medication adherence, and self-care strategies.
• Promote preventative care practices and patient engagement in long term health management.

Care Coordination

• Collaborate with physicians, nurses, social workers, and partner healthcare organizations to ensure seamless care coordination.
• Work closely with the Chief Medical Officer and clinical leadership team to support clinical program development and care delivery models.

Documentation

• Maintain accurate and timely documentation within the electronic health record system.
• Ensure patient documentation aligns with regulatory requirements and organizational policies.
• Participate in quality improvement initiatives to enhance patient outcomes and care delivery processes.

Program Leadership & Strategy: Support the implementation and advancement of Ponos Care’s clinical care model for chronic disease management. Contribute to the development and implementation of clinical protocols, guidelines, and treatment pathways. Assist leadership in evaluating patient care outcomes and identifying opportunities for program improvement. Support interdisciplinary collaboration to strengthen patient care delivery and care coordination efforts.

Regulatory & Compliance Oversight: Ensure adherence to federal, state, and local healthcare regulations and clinical practice standards. Maintain compliance with Virginia licensing requirements and healthcare regulatory guidelines. Follow HIPAA standards and organizational policies for patient privacy and data protection. Participate in clinical audits, documentation reviews, and compliance related initiatives.

Operational Excellence & Performance Management: Support the continuous improvement of clinical operations through data driven decision making. Monitor patient outcomes and care plan effectiveness. Maintain accurate documentation and reporting within the electronic health record system. Assist with workflow improvements that enhance care coordination and patient engagement.

Team Leadership & Development: Collaborate with interdisciplinary care teams including physicians, nurses, social workers, and care coordinators. Serve as a clinical resource for team members regarding chronic disease management best practices. Support knowledge sharing and professional development within the clinical team. Promote a culture of collaboration, accountability, and patient centered care.

Innovation & Growth: Contribute to innovative approaches to chronic disease management within home based and mobile healthcare models. Support the adoption of telehealth technologies and digital healthcare tools. Identify opportunities to enhance patient engagement and improve health outcomes.

Participate in initiatives that support the continued expansion of Ponos Care services.

QUALIFICATIONS AND EDUCATION

• Certified Nurse Practitioner with an unrestricted license to practice in the Commonwealth of Virginia.
• Minimum of three years of clinical experience, preferably supporting chronic disease populations.
• Clinical experience in hematology, rheumatology, or gastroenterology populations preferred.
• Strong clinical assessment and diagnostic capabilities.
• Excellent communication and interpersonal skills.
• Ability to work independently and within a multidisciplinary team environment.
• Proficiency in electronic health records and healthcare technology platforms.
• Commitment to delivering high quality patient-centered care.
• Bilingual skills are 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. We are committed to providing reasonable accommodation for qualified individuals with disabilities throughout the recruitment and employment process.