Palliative Care RN

ChenMed•Selma, AL

6d•$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 care and specialty care team members, the RN builds trust with patients facing serious, 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 care settings; and escalates cases that exceed nurse-level management to a Physician/NP. The role focuses on identifying decline early, managing symptoms at home, preventing unnecessary emergency department visits and hospitalizations, and helping patients and families navigate transitions of care, including community-based hospice transitions when appropriate. The position involves locally traveling across a defined market service area, with home-, center-, and facility-based visits.

Requirements

Active, unencumbered Registered Nurse (RN) 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 (AHA) or American Red Cross.
Current, valid driver’s license and reliable transportation; willingness to obtain a compact RN license.
Competent business acuity in Medicare Advantage, value-based/full-capitation economics, and serious illness/palliative care program operations.
Knowledge of palliative and serious illness nursing practices and processes, validated assessment tools (ESAS-r, FRAIL Scale, ECOG Performance Status), and the Door 1/Door 2 escalation model.
Strong clinical judgment and ability to recognize and apply Door 1/Door 2 escalation criteria appropriately.
Ability to build rapport and trust with seniors and patients managing serious, advanced illness, as well as caregivers and families.
Excellent verbal and written communication skills with patients, families, specialists, and physicians.
Ability to recognize early clinical deterioration and caregiver strain or burnout.
Care coordination skills across specialists, hospitals, PCPs, and hospice partners.
Comfort conducting home-, center-, and facility-based visits across a defined market service area.
Proficiency with Microsoft Office Suite, 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.
Fluency in spoken and written 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/PCP referrals, and complete first outreach within 48 hours.
Review the patient’s chart before first contact, including diagnoses, specialist contacts, recent hospitalizations, medications, and advance directives.
Build rapport with newly identified patients and schedule an initial home- or center-based assessment; coordinate scheduling of the Palliative Care provider with specialty care team members.
Obtain verbal consent by phone and written consent at the first visit; document preferred contact methods and caregiver information.
Confirm and document specialist contacts and obtain releases of information; for oncology patients referred through the CPL partnership, confirm the co-management plan with the oncology practice.
Conduct comprehensive head-to-toe 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 available PRN medications and confirming that the patient and caregiver know how to use them safely.
Review and document goals of care, advance directive status, POLST/DNAR status, and healthcare surrogate or power of attorney designation at every visit; confirm family readiness before transmitting a hospice referral.
Determine and adjust visit frequency using patient Tier assignment, ECOG grade, ESAS score, and program guidelines; maintain at least weekly contact with every Tier 1 patient and contact with every Tier 2 patient at least every 3–4 weeks, increasing frequency as needed.
Assess whether a model-generated signal warrants escalation into the panel or return to surveillance; conduct an assessment when a signal fires without treating it as automatic enrollment.
Recognize and act on Door 1 and Door 2 escalation paths to the co-located Physician/NP; communicate clinical changes, medication concerns, symptom scores, and goals-of-care updates promptly and accurately to the Physician/NP and PCP.
Work within licensed scope of practice and applicable state regulations, escalating cases that require physician direction rather than independently managing them.
Manage the full course of hospital admissions for enrolled patients, 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 keep goal-concordant care central; schedule or confirm post-discharge follow-ups, specialist visits, home health services, and diagnostic testing, making calls on the patient’s behalf when needed.
Partner with Specialty Care Coordinators and the hospice partner network to arrange a warm transfer when clinical trajectory, physician order, or patient wishes indicate hospice is appropriate; attest to family readiness before transmitting the referral.
Support patients and families through serious illness with empathy, clear communication, and follow-through; identify caregiver strain or burnout and coordinate social work referrals as needed.
Document every patient contact within 24 hours and record assessment tool scores, escalations, medication changes, and care plan updates in the program dashboard according to program standards.
Perform other duties as assigned and modified at the manager’s discretion.