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- RN Patient Care Coordinator (RN PCC)
Description
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.
Requirements
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
