Palliative Care RN

ChenMed•Louisville, KY

8d•$37 - $53•Onsite

About The Position

The Supportive Care RN provides clinical and operational care for patients in the market’s serious-illness management panel who need active palliative care involvement. Working alongside palliative and specialty care teams, the RN builds trust with patients facing serious or advanced illness, conducts comprehensive assessments in homes, centers, or other facilities, monitors for early signs of clinical deterioration, validates findings with the patient’s PCP, coordinates care across specialists and settings, and escalates cases that exceed nurse-level management to a Physician or Nurse Practitioner. The role supports early identification of decline, symptom management at home, prevention of unnecessary emergency department visits and hospitalizations, and care transitions, including appropriate community-based hospice transitions. The RN identifies and contacts patients, reviews their records, obtains consent, and schedules assessments. The role includes comprehensive clinical assessments using validated tools, ongoing monitoring based on patient needs and program guidelines, collaboration with physicians and PCPs, coordination of hospital admissions and discharges, and psychosocial support for patients and caregivers. All patient contacts and clinical updates must be documented according to program standards. The position requires an active, unencumbered RN license in the state of practice, an ADN or higher, at least two years of clinical nursing experience, BLS certification, a valid driver’s license, and reliable transportation. Local travel may be required up to 75% of the time, with flexibility to work evenings, weekends, or holidays as needed. The hourly pay range is $36.90–$52.70. The position may also be eligible for bonuses or commissions.

Requirements

Active, unencumbered Registered Nurse license in the state of practice.
Associate Degree in Nursing (ADN) minimum.
At least 2 years of clinical nursing work experience.
Basic Life Support (BLS) certification from the American Heart Association or American Red Cross.
Current, valid driver’s license and reliable transportation.
Willingness to obtain a compact RN license.
Knowledge of palliative and serious-illness nursing practices, processes, procedures, and methods, including validated assessment tools and the Door 1/Door 2 escalation model.
Strong clinical judgment and ability to recognize and apply Door 1/Door 2 escalation criteria promptly and appropriately.
Ability to build rapport and trust with seniors and patients with serious, advanced illness, as well as caregivers and families.
Excellent verbal and written communication skills.
Ability to recognize early signs of clinical deterioration and caregiver strain or burnout.
Skill in coordinating care across specialists, hospitals, PCPs, and hospice partners.
Ability to conduct home-, center-, and facility-based visits across a defined market service area.
Proficiency with Microsoft Office products, including Excel, Word, PowerPoint, and Outlook, and competence with electronic health records and care management dashboards.
Ability and willingness to travel locally up to 75% of the time and work evenings, weekends, and/or holidays as needed.
Spoken and written fluency in English.
Ability to use and exercise independent judgment.

Nice To Haves

Bachelor of Science in Nursing (BSN).
Case management, oncology, cardiology, pulmonology, nephrology, home health, or hospice/palliative care experience.
Experience with patients with advanced solid tumors, NYHA Class III–IV heart failure, COPD GOLD 3–4, CKD Stage 4–5, or home oxygen dependency.
Bilingual ability matched to the language needs of the assigned market.
Certification in Hospice and Palliative Nursing (CHPN) or Oncology Nursing (OCN).

Responsibilities

Review daily Tier 1/2 signals and specialist or PCP referrals, and complete first outreach within 48 hours.
Review patient charts before first contact, including diagnoses, specialist contacts, recent hospitalizations, medications, and advance directives.
Build rapport with newly identified patients and schedule the first home- or center-based assessment.
Coordinate scheduling of palliative care providers with specialty care team members.
Obtain verbal consent by phone and written consent at the first visit; document contact preferences and caregiver information.
Confirm and document specialist contacts, obtain releases of information, and confirm oncology co-management plans for applicable CPL partnership referrals.
Conduct head-to-toe clinical assessments, including vital signs and neurological, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin, pain, and functional status assessments.
Administer and score ESAS-r and PPS at every visit, FRAIL Scale at initial assessment and every 90 days or sooner with clinical change, and ECOG Performance Status at every visit.
Complete pain, nutrition, and medication reviews, including checking PRN medication availability and confirming safe use by patients and caregivers.
Review and document goals of care, advance directives, POLST/DNAR status, and healthcare surrogate or power of attorney designation at every visit; confirm family readiness before hospice referral.
Adjust visit frequency and contact methods based on Tier assignment, ECOG grade, ESAS score, and program guidelines.
Maintain at least weekly contact with Tier 1 patients and contact Tier 2 patients at least every 3–4 weeks, increasing frequency when clinically indicated.
Assess whether model-generated signals warrant enrollment in the panel or return to surveillance; conduct an assessment when a signal fires without treating it as automatic enrollment.
Apply Door 1 and Door 2 escalation criteria and promptly communicate clinical changes, medication concerns, symptom scores, and goals-of-care updates to the Physician/NP and patient’s PCP.
Work within licensed scope of practice and applicable state regulations, escalating matters requiring physician direction.
Manage the full course of enrolled-patient hospital admissions, including same-day detection, in-hospital engagement, discharge coordination, medication reconciliation, and a post-discharge home visit within 48–72 hours.
Coordinate care with internal and external specialists to support goal-concordant care.
Schedule or confirm post-discharge appointments, specialist visits, home health services, and diagnostic testing, making calls on the patient’s behalf when needed.
Partner with Specialty Care Coordinators and hospice partners to arrange warm hospice transfers when indicated, confirming family readiness before referral transmission.
Support patients and families with empathy, clear communication, and consistent follow-through.
Identify caregiver strain or burnout and coordinate social work referrals as needed.
Document every patient contact within 24 hours and record assessment scores, escalations, medication changes, and care plan updates in the program dashboard.
Perform other duties as assigned and modified at the manager’s discretion.