Supportive Care, RN

ChenMed•Lakeland, FL

7d•$37 - $53•Hybrid

About The Position

The Supportive Care, RN is responsible for the clinical and operational care of patient engagement for the serious illness management panel in the market who need active palliative care involvement. Working alongside palliative care and specialty care team members, this position builds trust with patients facing serious, advanced illness; conducts comprehensive assessments in the home, center, or other facilities; monitors proactively for early signs of clinical deterioration; validates findings with the patient’s PCP; coordinates care across specialists and care settings; and escalates to the Physician/NP when a case exceeds nurse-level management. This role is essential to identifying decline early, managing symptoms at home, preventing unnecessary emergency department visits and hospitalizations, and helping patients and families navigate transitions of care — including, when appropriate, timely and compassionate hospice transitions that originate in the community rather than from a hospital bed.

Requirements

Active, unencumbered Registered Nurse (RN) license in the state of practice required
Associate Degree in Nursing (ADN) minimum
A minimum of 2 years’ work experience in clinical nursing required
Basic Life Support (BLS) certification from the American Heart Association (AHA) or American Red Cross required
This position requires possession and maintenance of a current, valid Driver’s License and reliable transportation.
Willingness to obtain a compact RN license.

Nice To Haves

Bachelor of Science in Nursing (BSN) preferred
Case management, oncology, cardiology, pulmonology, nephrology, home health, or hospice/palliative care experience strongly preferred.
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 preferred.
Bilingual, matched to the language needs of the assigned market, preferred.
Certification in Hospice and Palliative Nursing (CHPN) or Oncology Nursing (OCN) preferred.

Responsibilities

Reviews daily all Tier 1/2 signals and specialist/PCP referrals, and complete first outreach within 48 hours.
Reviews the patient’s chart before first contact, including diagnosis, specialist contacts, recent hospitalizations, medications, and advance directives.
Builds initial trust and rapport with newly identified patients and schedule the first home or center-based assessment visit.
Coordinates scheduling of Palliative Care provider with specialty care team members.
Obtains verbal consent by phone and written consent at the first visit; document preferred contact methods and caregiver information.
Confirms and documents specialist contacts (oncology, cardiology, nephrology, pulmonology) and obtains releases of information; for oncology patients referred through the CPL partnership, confirm the co-management plan with the oncology practice.
Conducts head-to-toe assessments covering vital signs, neurological, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin/integument, pain, and functional status.
Administers and scores validated clinical tools at each required interval: the Edmonton Symptom Assessment System (ESAS-r) at every visit, the Palliative Care Performance Scale (PPS) at every visit, the FRAIL Scale at initial assessment and every 90 days (or sooner with clinical change), and ECOG Performance Status at every visit.
Complete detailed pain, nutrition and medication reviews, including a check of PRN medications available in the home, center or dwelling and confirmation 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 any hospice referral is transmitted.
Determine and adjust visit frequency — face to face visits, telehealth, or phone check-ins based on the patient’s Tier assignment, ECOG grade, and ESAS score, following program guidelines.
Maintain, at minimum, weekly contact with every Tier 1 patient (a non-negotiable cadence floor) and contact with every Tier 2 patient at least every 3–4 weeks, increasing frequency as clinical presentation requires.
Assess whether a model-generated signal warrants escalation into the panel or a return to surveillance; a fired signal obligates an assessment, not an automatic enrollment.
Recognize and act on the two defined escalation paths to the co-located Physician/NP: Door 1, when a PCP, specialist, or the National Medical Director directly requests a physician-level consult; and Door 2, when the Serious Illness Care Guide own escalation criteria are met — a Tier 1 symptom unlikely to resolve at nurse level, a controlled-substance or complex prescribing decision, or a suspected hospice-eligibility determination.
Communicate clinical changes, medication concerns, symptom scores, and goals-of-care updates to the Physician/NP and the patient’s PCP promptly, accurately, and completely.
Function within licensed scope of practice and applicable state regulations at all times; escalate rather than independently manage changes that require physician direction. No AI tier, score, or trigger alone routes a case to the physician — only Door 1 or Door 2.
Manage the full arc of any hospital admission for an enrolled patient: same-day detection, in-hospital engagement, discharge coordination, medication reconciliation, and the post-discharge home visit within 48–72 hours of discharge.
Coordinate Care with internal and external specialists that patients are seeing to ensure that goal concordant care is at the center of the care.
Schedule or confirm all post-discharge follow-up appointments, specialist visits, home health services, and diagnostic testing making calls on the patient’s behalf when needed.
Partner with the Specialty Care Coordinators and the hospice partner network to activate a warm transfer when clinical trajectory, physician order, or patient wishes indicate hospice is appropriate — with family readiness attested before the referral is transmitted.
Supports patients and families through serious illness with empathy, clear communication, and consistent follow-through.
Identifies signs of caregiver strain or burnout and coordinate social work referrals as needed.
Documents every patient contact — face to face visit, phone call, or telehealth — within 24 hours.
Records all assessment tool scores, Door 1/Door 2 escalations, medication changes, and care plan updates in the program dashboard, meeting all documentation standards defined by the program.
Performs other duties as assigned and modified at manager’s discretion.