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Job Summary: The Palliative Care Nurse is a vital member of the interdisciplinary team, working collaboratively with the Nurse Practitioner and Medical Assistant to deliver compassionate, patient-centered care. This role involves active engagement with patients, families, caregivers, referral sources, facilities, and other healthcare providers to ensure coordinated and responsive care. Strong clinical assessment and therapeutic communication skills are essential to identify patient and family needs, establish goals of care, and determine eligibility for palliative and hospice services. The Palliative Care Nurse must be skilled in guiding end-of-life conversations with empathy and professionalism. Core responsibilities include managing the intake of all palliative care patients, processing hospice referrals, responding to urgent triage needs, assisting with symptom management, and providing routine wellness calls as indicated.

Essential Functions:

+ Performs comprehensive intake assessments for all palliative care referrals to determine eligibility and appropriateness for services.

+ Processes admission information to ensure appropriate clinical documentation is obtained, referral sources are updated, and the electronic medical record (EMR) contains complete and accurate information.

+ Establishes patient profile in the electronic prescribing system to support timely and accurate medication management.

+ Educates patients and families during intake and wellness calls on the goals, benefits, and eligibility criteria for both palliative and hospice care.

+ Provides ongoing education related to symptom management, disease progression, self-care strategies, and available services.

+ Ensures all intake and admission components are completed, including consents and required medical paperwork.

+ Maintains accurate and timely documentation in the EMR to support continuity of care across the interdisciplinary team.

+ Actively obtains and tracks relevant clinical records and updates from community providers, facilities, and specialists to inform treatment planning and transitions of care.

+ Works closely with the Nurse Practitioner and Medical Assistant to ensure seamless care delivery and timely transition to hospice services when appropriate.

+ Participates in monthly Interdisciplinary Team (IDT) meetings to contribute to care planning and ensure patient and family needs are met.

+ Responds to triage calls to assess symptoms and ensure timely, appropriate interventions in collaboration with the provider.

+ Addresses patient and caregiver needs with a therapeutic, compassionate, and flexible approach, based on the acuity and urgency of the situation.

+ Completes routine wellness calls for all palliative care patients as guided by patient acuity and Nurse Practitioner direction.

+ Provides psychosocial support and reinforce individualized self-care strategies to enhance patient and caregiver confidence.

+ Delivers patient and caregiver education via phone on medications, diet, comfort measures, and other provider-directed care plans.

+ Maintains and enhances professional skills through ongoing education and training.

+ Remains current on developments in palliative care and share relevant updates with the care team.

+ Complies with local, state, and federal regulations, agency policies, Quality Partners standards, and privacy guidelines including HIPAA.

+ Assists with MA or nursing coverage as needed during staff PTO/CTO or other leaves of absence.

+ Demonstrates understanding of the Medical Assistant role and assist with non-licensed tasks as appropriate.

+ Promotes positive community relations through professional, compassionate service.

+ Represents the agency's mission, vision, and the core philosophy of palliative and hospice care in all patient and stakeholder interactions.

+ Completes special projects, chart audits, workflow improvements, and other assignments as delegated.

+ Actively participate in organization-wide performance improvement initiatives.

+ Adheres to the organizational Code of conduct and all departmental and organizational policies, procedures, protocols, practices and all regulatory and legal requirements.

+ Adheres to the NorthStar standards to care for every person, every time, 100% of the time.