RN Care Coordinator - Palliative Care - Center City, PA

Job Details

• Hybrid role with a mix of remote administrative / triage work and in-person visits / meetings as required.

Potential for home-based visits.

Typical work schedule is Monday-Friday, 40 hours per week, with occasional flexibility for patient or team needs.

The Home-Based Palliative Care Registered Nurse (RN) plays a key role in expanding access to high-quality, patient-centered palliative care within the community. This position is responsible for patient triage, coordination, and care assessment for individuals referred to the home-based palliative care program. The RN ensures appropriate patient inclusion, facilitates continuity across settings, and supports the delivery of compassionate, goal-directed care for patients with serious illness.

This role also includes outreach and collaboration with key stakeholders, liaison work between inpatient and home-based palliative care teams, and participation in interdisciplinary and divisional meetings. The position offers a hybrid work model, with a mix of remote and in-person responsibilities.

Interact with co-workers, patients, their family / designated care partner(s), and other staff consistent with the values of Jefferson.

Integrates Evidence-Based Practice, clinical expertise, patients, their family / designated care partner(s) preferences and cultural beliefs and values for delivery of optimal healthcare.

Partners with patients, their family / designated care partner(s)) in identifying learning needs and priorities and providing education in ways that are useful, understandable, and affirming.

Recognizes the patients, their family / designated care partner(s) in providing safe, compassionate and coordinated care based on respect for patient's preferences, priorities, needs, and cultural beliefs and values.

Creates an environment of belonging and inclusion and demonstrates skills in problem solving and conflict resolution.

Supports telehealth and home-based assessments for patients.

Determine whether patients meet the scope and criteria for palliative care services.

Identify needs related to symptom management, psychosocial support, and advance care planning.

Conduct ad hoc Goals of Care and Advance Care Planning discussions by phone or in person, as appropriate.

Serve as a liaison between inpatient palliative care teams, home-based providers, and community partners to ensure seamless transitions of care.

Collaborate with referring clinicians, home health agencies, and specialty services to facilitate comprehensive support for patients and families.

Attend weekly interdisciplinary team (IDT) meetings to review cases and update care plans.

Participate in regular Division of Palliative Care meetings to align with system goals and initiatives.

Contribute to quality improvement efforts, data tracking, and program development initiatives.

Participate in marketing and outreach efforts, including meetings with key stakeholders to promote program awareness and referrals.

Receive and review referrals for home-based palliative care.

Conduct initial triage calls to assess patient eligibility and urgency.

Schedule visits and coordinate provider assignments in collaboration with the interdisciplinary team.

Collaborate, communicate and coordinate care for patients and populations across the care continuum (home, physician office, hospital).

Evaluation of Hospital at Home patient screening lists and appropriately proactively engage patients and care team members to coordinate transition from hospital to home.

Potential to support in on site home visits.

Timely and ongoing communication with the assigned licensed independent provider and other acute care team members to provide a streamlined, coordinated approach to care for the patient and family / designated care partner(s) in order to optimally manage patient needs, reduce risk or poor health outcomes, and ensure safe provision of care.

Actively engages in ongoing assessment and improvement of palliative care ambulatory program to improve systems, processes, policies.

Job Description

Education :

Graduate of an accredited school of nursing required; BSN or completion of BSN within 3 years of hire strongly preferred

AND

Experience :

Required :

Minimum of 3 years of clinical nursing experience , preferably in palliative care, hospice, home health, or complex chronic disease management.

Strong clinical assessment and communication skills.

Demonstrated ability to work independently and collaboratively within an interdisciplinary team.

Preferred :

Experience in palliative care or serious illness management.

Certification in Hospice and Palliative Nursing (CHPN) or willingness to obtain within 1 year of hire.

Experience with EMR systems and telehealth tools.

Current RN licensure in state of employment; AHA BLS CPR certification

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Jefferson University Physicians

Primary Location Address

833 Chestnut Street, Philadelphia, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic / programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.

Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

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