Palliative Care Nurse Navigator

Job Description

Job Description

Position Summary :

The Palliative Care Nurse Navigator (PCNN) will work in collaboration with the palliative care team to provide services to patients and families in a variety of home settings. This position serves as a patient advocate, educator, and care coordinator, providing specialized nursing support for patients with a serious illness and their family. The role involves collaborating with interdisciplinary teams to facilitate seamless care, improve quality of life, and ensure patients and their families are informed and supported. The PCNN communicates in a sensitive, professional, and empathetic manner.

This position works collaboratively with the intake team and the providers to expedite referral approval. This position reviews records and communicates with hospitals, facilities, clinic offices, patients, and families as needed to gather information. The PCNN communicates clinical eligibility criteria to the provider via written summaries and collaborates with the Medical Director. The PCNN has an excellent understanding of palliative care and hospice eligibility requirements.

Essential Functions :

1. Implement the strategy for the RPC team in alignment with the overall Sharon S. Richardson Community Hospice (SSRCH) strategy to increase growth and representation of people being served.

2. Serves as a central point of contact for all patient centered activities including qualifying new referrals, scheduling of visits, stratifying of patients, addressing patient concerns and needs, facilitating responses with providers, initiating and assisting in goals of care discussions, and following up with patients and families.

3. Provides compassionate, patient-centered care in-person, on the phone, or virtually that aligns with the patient’s goals and values.

4. Assesses and monitors patients’ symptoms and emotional health, offering expertise in pain and symptom management strategies.

5. Educates patients and families about illness progression, palliative treatments, medications, grief, and care options. Makes appropriate community and organizational referrals.

6. Leads interdisciplinary team meetings to evaluate patient needs and adjusts care plans as necessary.

7. Demonstrates expert techniques in clinical and supportive skills to improve referrals to RPC.

8. Ensures that RPC’s clinical practice supports the regulatory needs of our referral partners.

9. Serves as a speaker in outreach activities to educate long-term care and healthcare referral sources, community professionals, influencers, and consumers about palliative care and RPC.

10. Supports the admission and discharge processes as needed.

11. Responsible for accurate and timely documentation in EMR.

12. Provides timely and appropriate response to internal and external customer needs.

13. Offers suggestions to improve policies, procedures, and services in an appropriate manner.

14. Demonstrates understanding of, and acts in accordance with, HIPAA Privacy Standards, Corporate Compliance, Code of Conduct, and related agency policies.

15. Participates in performance evaluation process for palliative care. Assists with performance improvement plans as needed.

16. Participates in SSRCH provided education and employee meetings.

17. All other duties as assigned.

Working Conditions :

1. Physical Requirements : Manual dexterity to operate computer, phone, and other office equipment. Able to sit for extended periods of time. Ability to have hearing and vision correctable to normal levels. Ability to locate and drive to and from facilities, patient’s homes, and to meetings at other locations as necessary. Ability to ambulate on a frequent basis, constant bending, lifting, and twisting.

2. Mental Requirements : Read, speak, write and understand English; critical thinking skills; ability to add, subtract, multiply, divide and work with fractions; must be able to work independently with indirect supervision.

3. Working / Environmental Conditions : Fast-paced changing environment, with multiple directives from several disciplines; may require work in patient homes with no control over environmental conditions.

4. Machines, Equipment, Tools Used : Telephone, computer, copy machine. Will require personal vehicle to travel to various facilities and patient’s homes as needed.

5. Exposures : Possible exposure to blood, other body fluids or other potentially infectious materials. Possible exposure to communicable diseases or infections. Possible exposure to hazardous equipment, assorted chemicals, gases / vapors, and other pollutants.

Professional Qualifications :

1. Certificate / Degree / License Requirements : Licensed practical (LPN), vocational, or registered nurse (RN) required. CHPLN® required within 2 years of hire, valid Wisconsin driver’s license upon hire, recertification as required. Must carry car insurance on vehicle used to perform job and an acceptable driving record.

2. Experience Requirements : Minimum of five years palliative, public health, home health nursing or hospice experience. Experience delivering educational offerings (preferred).

3. Competencies : Business acumen with demonstrated ability to understand long-term care, assisted living facilities and medical practice’s function and how to build effective business relationships. Excellent customer service, strong communication, listening, written and interpersonal communication skills. Empathy, cultural sensitivity and emotional resilience. Ability to manage complex care needs and prioritize in dynamic environment.

4. Computer Skills : Proficiency in the use of Microsoft Office and EMR documentation familiarity preferred.