RN- Care Coordinator- Illness Services

RN
- Care Coordinator
- Serious Illness Services, Full-time

Job Category:
Palliative Care Nurse

Requisition Number: PALLI
001111

Job Summary:

The RN Care Coordinator position is an on-site position, requiring in-person visits with patients in their homes. This is not a remote position.

This is a full-time professional position providing nursing care coordination for patients enrolled in Serious Illness Services with a special focus on patients and caregivers seeking to enroll in the GUIDE program. This role includes direct patient and caregiver contact through a hybrid model of care, combining community-based visits, and telehealth encounters (phone or video).

The Care Coordinator RN delivers education, assessment, and ongoing support based on individualized program guidelines and collaborates closely with interdisciplinary team members and referral sources. The schedule for this position is Monday–Friday, 8:30am–5:00pm; weekends and holidays TBD.

Responsibilities—What You Do

Clinical & Care Coordination

• Provide safe, competent, compassionate care and coordination to patients in Serious Illness Services, with an ongoing special focus on the GUIDE dementia care program. This role serves as a primary point of contact and care navigation for our GUIDE patients and caregivers.
• Conduct comprehensive in-home and telehealth assessments for patients, evaluating caregiver needs, home safety, behavioral symptoms, and disease progression, including GUIDE related documentation, record keeping and data submission for CMS compliance.
• Deliver disease specific education, care planning, and ongoing coaching to caregivers.
• Triage phone calls for patients as needed to support Serious Illness Services.
• Provide appropriate end-of-life (EOL) information, anticipatory guidance, and education to patients, families, and hospital or facility staff as applicable.

Interdisciplinary Collaboration & Support

• Support clinicians in the field regarding administrative and clinical coordination needs.
• Collaborate with MSWs and other interdisciplinary team members to coordinate care and facilitate visits across service lines.
• Participate actively in interdisciplinary team meetings.
• Assist in the transfer of patients and/or information between programs in collaboration with appropriate team members.

Program & Administrative Responsibilities

• Ensure all required dementia program documentation, tracking elements, assessments, and care plans are completed according to CMS guidelines.
• Provide information about available community resources, including dementia specific, disease specific support.
• Accurately document all contacts, assessments, and communications in the electronic medical record.
• Assist with data collection and reporting needs for Serious Illness and dementia care programs.
• Demonstrate willingness to cross train across service lines and support additional areas of clinical need.
• Perform other duties as assigned by the supervisor.

Expectations—How You Do It

• Exemplify TL Core Values in all interactions with patients, families, colleagues, and referral sources.
• Demonstrate excellent customer service skills and positive, compassionate communication.
• Adhere to TL policies, procedures, and clinical guidelines.
• Follow CMS and state regulations, nursing standards of practice, NHPCO Ethical Practices, and the American Nurses Association's Code of Ethics.
• Maintain confidentiality, professionalism, and clinical integrity in all aspects of care.

Requirements—What You Need

• Registered Nurse with current NC license; BSN preferred.
• CHPN certification or willingness to complete certification within 2 years.
• At least 3 years of clinical experience; at least 2 years of home health, geriatrics, palliative care and/or hospice experience or equivalent.
• Experience with dementia care preferred; willingness to obtain dementia specific training required for program compliance.
• Excellent verbal and written communication skills.
• Ability to multitask and coordinate multiple complex clinical workflows.
• Proficient computer skills and comfort with telehealth platforms.
• Current CPR certification.
• Reliable transportation and the ability to travel to, enter, and function in patient…