Supportive Care, Registered Nurse (RN)

Supportive Care, RN

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The Supportive Care, RN is 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.

ESSENTIAL JOB DUTIES/RESPONSIBILITIES:

Patient Identification, Outreach, and Enrollment

• 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.

Comprehensive Clinical Assessment

• 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.

Ongoing Monitoring and Visit Cadence

• 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 34 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.

Physician/NP Collaboration and Door 1 / Door 2 Escalation

• 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.

Care Coordination and Transitions of Care

• 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 4872 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.

Psychosocial Support and Caregiver Engagement

• 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.

Documentation

• 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.

KNOWLEDGE, SKILLS AND ABILITIES:

• Competent-level business acuity in Medicare Advantage, value-based/full-capitation economics, and serious illness/palliative care program operations.
• Comprehensive knowledge and understanding of general/core job-related functions, practices, processes, procedures, techniques, and methods for palliative and serious illness nursing, including validated assessment tools (ESAS-r, FRAIL Scale, ECOG Performance Status) and the Door 1/Door 2 escalation model.
• Strong clinical judgment and the ability to recognize and apply Door 1/Door 2 escalation criteria promptly and appropriately.
• Ability to build rapport and trust quickly with seniors and patients managing serious, advanced illness, and with their caregivers and families.
• Excellent verbal and written communication skills with patients, families, specialists, and physicians.
• Ability to recognize early signs of clinical deterioration and caregiver strain or burnout.
• Skilled at cross-functional care coordination across specialists, hospitals, PCPs, and the hospice partner network.
• Comfortable conducting home-based, center-based, and facility-based visits across a defined market service area.
• Proficient skill in Microsoft Office Suite products including Excel, Word, PowerPoint and Outlook; competent in electronic health records and care management dashboards required for the position.
• Ability and willingness to travel locally up to 75% of the time; flexible to work evenings, weekends and/or holidays as needed.
• Spoken and written fluency in English
• This job requires use and exercise of independent judgment.

EDUCATION AND EXPERIENCE CRITERIA:

• Active, unencumbered Registered Nurse (RN) license in the state of practice required; Associate Degree in Nursing (ADN) minimum, Bachelor of Science in Nursing (BSN) preferred.
• A minimum of 2 years' work experience in clinical nursing required.
• Case management, oncology, cardiology, pulmonology, nephrology, home health, or hospice/palliative care experience strongly preferred.
• Experience with patients with advanced solid tumors, NYHA Class IIIIV heart failure, COPD GOLD 34, CKD Stage 45, or home oxygen dependency preferred.
• Bilingual, matched to the language needs of the assigned market, preferred.