What are the responsibilities and job description for the RN - Patient Care Coordinator position at Seasons Hospice?
Department Nursing
Location Homecare/Office
Reports to Clinical Services Manager
Next Review Date 12/2025
Mission Statement
To provide individualized and compassionate care, education, and support for the dying and those who have
experienced loss.
Position Summary
This position is responsible for coordinating and overseeing the delivery of comprehensive care to hospice patients
wherever they call home in accordance with the Interdisciplinary Team (IDT) Plan of Care.
Position Qualifications
- Education and Training:
o Required: Associate’s or Bachelor’s degree in Nursing from a nursing program. If the nursing program
was not accredited, at least one year of RN experience in an applicable care setting required.
o Preferred: Associate’s or Bachelor’s degree in Nursing from an accredited nursing program.
- Experience:
o Preferred: 2 years of experience working as an RN in a healthcare or hospice setting.
- License or Certification:
o Required: Active and unrestricted RN license in MN.
o Required: Basic Cardiac Life Support for healthcare providers. Must complete within 3 months after start
date if certification is not current.
o Required: Valid driver’s license with acceptable driving record.
Position Duties and Responsibilities
- Assessment and Care Planning:
o Conduct comprehensive assessments of patients' physical, psychosocial, and spiritual needs,
collaborating with the interdisciplinary team to develop individualized care plans.
o Evaluate patients' symptoms, pain levels, and overall well-being, identifying areas for intervention and
developing appropriate care strategies.
o Coordinate with members of the interdisciplinary team to ensure holistic care planning that addresses
patients' diverse needs and preferences.
- Skilled Nursing Care:
o Provide skilled nursing interventions and treatments to address patients' clinical needs, including
medication administration, wound care, pain management, and symptom control.
o Monitor patients' response to treatment, assess for changes in condition or symptom progression, and
collaborate with the interdisciplinary team to adjust care plans accordingly.
o Offer emotional support, counseling, and education to patients and families, addressing concerns,
fears, and questions related to end-of-life care and symptom management.
- Coordination of Care:
o Serve as the primary point of contact for patients, families, and caregivers, coordinating care services,
scheduling visits, and ensuring continuity of care.
o Facilitate communication and collaboration among interdisciplinary team members, ensuring that care
plans are implemented effectively and consistently.
o Coordinate transitions of care, including admissions, discharges, and transfers, to ensure seamless
transitions and optimal patient outcomes.
o Conduct regular case conferences, team meetings, and interdisciplinary rounds to review patient
status, discuss care plans, and address complex clinical issues.
o Participate in interdisciplinary team meetings, care conferences, and care planning sessions to review
patients’ progress, discuss care goals, update patient care plans and address any other patient care
concerns.
- Clinical Oversight and Support:
o Provide clinical oversight, support, and training to other nursing and hospice aide staff, guiding them in
the delivery of high-quality, compassionate care to hospice patients.
o Responsible for completing Hospice Aide supervisory visits; as required.
- Patient and Family Education:
o Provide education and support to patients, families, and caregivers about hospice services, goals of
care, symptom management, and end-of-life care options.
o Offer guidance and resources to help patients and families navigate the hospice experience, including
advance care planning, community resources, and psychosocial support services.
o Empower patients and families to actively participate in their care journey, advocating for their
preferences, values, and goals throughout the hospice experience.
- Patient and Family Advocacy:
o Advocate for the needs and preferences of patients and families, ensuring that their voices are heard
and respected throughout the care process.
o Provide emotional support and education to patients and families, addressing concerns, fears, and
questions related to end-of-life care.
o Collaborate with social workers, chaplains, and other support services to provide comprehensive
psychosocial and spiritual support to patients and families.
- Documentation and Regulatory Compliance:
o Maintain accurate and timely documentation of assessments, interventions, and patient/family
interactions in patients' electronic medical record and other required documentation systems, within 24
hours of contact.
o Ensure compliance with Medicare Hospice regulatory standards and MN Standards of Practice.
o Provide care consistent with National Hospice and Palliative Care Organization Standards of Practice
for Hospice Programs.
- Professional Development and Training:
o Participate in ongoing professional development activities, including continuing education and training
to enhance skills and knowledge.
o Stay informed about best practices and emerging trends in clinical hospice care.
- Other Duties
o Participates in on-call/holiday rotation.
o Participate in coverage for PTO taken by the On Call RN position.
o Serve in the role of back up Admission RN; as needed.
o Cover nursing shifts at the Hospice House, as needed or available.
Physical Demands
Sedentary (Requires lifting 10 lbs., carrying small objects)
Light (Requires lifting 20 lbs., with occasional carrying of up to 20 lbs.)
Medium (Requires lifting 50 lbs., with occasional carrying of up to 25 lbs.)
Heavy (Requires lifting 100 lbs., with occasional carrying of up to 50 lbs.)
Very Heavy (Requires lifting over 100 lbs., with occasional carrying of up to 50 lbs.)
Supervising Responsibilities
Yes - The position has direct supervising responsibilities
No - The position does not have supervising responsibilities
Travel Requirements
The position requires regular use of an insured, reliable vehicle for travel throughout Seasons Hospice service area.
The position requires occasional use of an insured, reliable vehicle for travel.
The position does not require travel.
Agency Expectations
- Adhere to all Seasons Hospice policies and procedures.
- Adhere to the Seasons Hospice Behavior Standards.
- Adhere to all Health Insurance Portability and Accountability Act (HIPAA) rules and regulations.
- Serve as an ambassador for Seasons Hospice.
- Support the patients and family’s unique spiritual and cultural beliefs.
- Respect for diversity in the workplace.
- Participate in the employee performance review process.
- Demonstrate ongoing responsibility for self-education.
- Maintain personal and patient safety, as appropriate to position in the agency.
- Actively participate in committees within the agency.
- Attend scheduled department meetings and agency meetings on a regular basis.
- Occasional flexibility with work schedule and regularly scheduled work hours.
- Participate in the Quality Assessment Performance Improvement Program (QAPI); as requested.
- Participate in orientation, training, and education of new employees and volunteers; as requested.
- Participate in orientation and supervision for students seeking experience in hospice care; as requested.
- Assume responsibility for the promotion of the hospice concept in the community and with other agencies and
professionals.
- Participate in orientation of new employees, as requested.
- Perform other duties as requested and/or assigned.
This job description is only a summary and is not designed to cover or contain a comprehensive listing of activities,
duties or responsibilities that are required of the employee. Nothing in this job description restricts management’s right to
assign or reassign duties and responsibilities to this job at any time. This job description is subject to change at any time
with or without notice.