• Conduct in-person and telephonic RN assessments and screenings for palliative care patients.
• Complete Risk Stratification Assessments to identify patient support needs in consultation with the Nurse Practitioner.
• Observe patient visit frequency based on individual needs and risk identification.
• Educate patients and families on disease processes, self-care, end-of-life care, medications, nutrition, and treatments.
• Communicate findings to the Palliative Nurse Practitioner and/or PCP, including changes in condition or signs of decline.
• Coordinate care with palliative team members and support hospice referral as appropriate.
• Document timely clinical records including assessments, progress notes, care plans, physician orders, and treatments.
• Support care plan development from initial assessment through discharge, addressing functional decline, symptom management, nutrition, cognition, and family/caregiver needs.
• Collaborate on modifications to individualized palliative plans of care.
• Facilitate care delivery and obtain additional resources as needed in accordance with the Plan of Care.
• Participate in evening/weekend on-call rotation as required.
• Facilitate prescription transmission to pharmacies, manage lab and diagnostic results, and request durable medical equipment as medically necessary.
• Maintain effective relationships with supportive care team members and other healthcare providers.
• Communicate and document clinical findings, treatment plans, and care provided in accordance with nursing standards and regulatory requirements.
• Adhere to company policies, HIPAA privacy standards, business ethics, and mandatory compliance programs.
• Implement marketing and promotional initiatives as directed.
• Perform other related duties as assigned.

Required Qualifications:

• Active and unrestricted Registered Nurse (RN) license with no board actions
• Minimum 2 years of clinical RN experience, preferably in skilled nursing, home health, palliative care, hospice, geriatrics, or oncology
• Demonstrated ability to provide quality care in high-empathy environments
• Proficiency in Microsoft Outlook, Word, Excel, and electronic medical records
• Exceptional communication, time management, and critical thinking skills
• Keen observation skills with the ability to identify changes in condition and escalate appropriately
• Comfortable working independently in the field and within interdisciplinary care models
• Valid driver’s license and reliable transportation (field-based role)

Preferred Experience:

• Previous experience in palliative care, hospice, or oncology nursing
• Familiarity with risk stratification, symptom management, and home-based care planning
• Experience working in or with assisted living and skilled nursing facilities