RN Care Coordinator Palliative Care

About the role

The RN Care Coordinator serves as the clinical extension of an assigned palliative care patient panel, delivering comprehensive nursing support. Working in partnership with the interdisciplinary team, the RN coordinates clinical care, performs symptom assessment and triage, manages patient communications, supports care transitions, and facilitates timely follow-up.

Responsibilities

• Serve as the primary clinical support resource for palliative patients.
• Execute delegated nursing interventions within RN scope.
• Review schedules and prepare patients for upcoming visits.
• Support follow-up on provider recommendations, orders, labs, imaging, referrals, and treatment plans.
• Communicate significant clinical changes promptly.
• Provide monthly Principal Care Management (PCM) services meeting CMS requirements.
• Assess symptoms, medication adherence, barriers to care, and changes in condition.
• Carefully coordinate care across providers and settings.
• Document PCM services to support compliance and billing.
• Maintain oversight of assigned patient panel.
• Perform proactive outreach after hospitalizations, ED visits, or symptom escalation.
• Monitor care gaps, quality metrics, and follow-up needs.
• Support continuity of care across the healthcare team.
• Triage incoming clinical calls and EMR messages.
• Provide patient education and reinforce provider care plans.
• Escalate urgent or complex issues appropriately.
• Coordinate referrals, diagnostics, DME, home health, hospice, and community resources.
• Facilitate care transitions and communication among treating clinicians.
• Manage provider inboxes, refills, orders, labs, and documentation workflows.
• Ensure timely, accurate EMR documentation.
• Track outstanding tasks until resolution.
• Participate in interdisciplinary care planning.
• Collaborate with physicians, APPs, RNs, social workers, facilities, and community partners.
• Support workflow optimization, reporting, quality metrics, and program development.

Requirements

• Education Requirements: CPR certification from the American Heart Association or American Red Cross Basic Life Support (BLS) is required.
• Graduate of an accredited RN program.
• Current NC RN license.
• Minimum 2 years RN experience in hospice and/or palliative care required.
• Case Management Certification preferred.
• Experience with EMR systems and Microsoft Office.
• Other: Valid state-issued driver's license required. Must carry automobile liability insurance at limits required by agency. Must have own transportation.

Qualifications and Skills

• Provider Clinical Support
• Serve as the primary clinical support resource for palliative patients.
• Execute delegated nursing interventions within RN scope.
• Review schedules and prepare patients for upcoming visits.
• Support follow-up on provider recommendations, orders, labs, imaging, referrals, and treatment plans.
• Communicate significant clinical changes promptly.
• Provide monthly Principal Care Management (PCM) services meeting CMS requirements.
• Assess symptoms, medication adherence, barriers to care, and changes in condition.
• Carefully coordinate care across providers and settings.
• Document PCM services to support compliance and billing.
• Maintain oversight of assigned patient panel.
• Perform proactive outreach after hospitalizations, ED visits, or symptom escalation.
• Monitor care gaps, quality metrics, and follow-up needs.
• Support continuity of care across the healthcare team.
• Triage incoming clinical calls and EMR messages.
• Provide patient education and reinforce provider care plans.
• Escalate urgent or complex issues appropriately.
• Coordinate referrals, diagnostics, DME, home health, hospice, and community resources.
• Facilitate care transitions and communication among treating clinicians.
• Manage provider inboxes, refills, orders, labs, and documentation workflows.
• Ensure timely, accurate EMR documentation.
• Track outstanding tasks until resolution.
• Participate in interdisciplinary care planning.
• Collaborate with physicians, APPs, RNs, social workers, facilities, and community partners.
• Support workflow optimization, reporting, quality metrics, and program development.

Benefits

Competitive salaries and a comprehensive benefit package which includes: Paid time off (PTO) plus 7 paid holidays, Medical, dental, vision, disability, and life insurance, 403B match after 12 months of service. Other benefits include mileage reimbursement, flexible work schedules, professional growth and development opportunities, and employee engagement activities.