VIA Health Partnersis an industry leader and top-10 nationally ranked provider of end-of-life care. More importantly, we are proud to be a community-based, not-for-profit hospice&palliative care provider. We have deep community roots, with decades of experience serving ALL patients and families needs regardless of their ability to pay or their medical complexity. We are a people-first organizationwhose funds go to serve our mission. Due to our significant growth, we are looking for amazing new staff who share these same values. Apply now and be a part of our success story. We provide excellent benefits including: Medical, Vision, and Dental plans through BCBS 28 days of Paid Time Off Excellent mileage reimbursement rate 403b Retirement plan with matching Focused programs honoring Veteran patients Assistance with achieving Certified Hospice&Palliative Nurse (CHPN) Best Orientation and Onboarding program youve experienced Seasoned Hospice leaders guiding your career growth Summary Responsible for presenting hospice services at the point of admission (home or community) for individuals and their families. Initiates individualized plan of care by working with patient, family, physician, and hospice interdisciplinary group to anticipate patient needs. Serves as the initial RN member of the interdisciplinary group to develop specific plan of care goals. Coordinates closely with related disciplines to ensure professional service delivery at the time of admission. Essential Functions Assumes responsibility for the effective coordination of patient/caregiver care Conducts admission nursing assessment to identify patient/caregiver needs. Develops plan of care for patients/caregivers. Incorporates therapeutic, preventive, and palliative nursing actions, and specifically addresses patient/caregiver education. Determines individualized goals and interventions on plan of care to meet patient and caregiver present physical, emotional, spiritual needs. Initiates and maintains a liaison relationship with healthcare providers to effectively coordinate multidisciplinary care. Consults with the patient, caregivers, physicians, facility staff and interdisciplinary team when initiating care. Reliably communicates pertinent information to appropriate members of the interdisciplinary team. Participates in admission interdisciplinary group conference (IDG). Communicates closely with the staff nurse assigned as the case manager to ensure clarity of care when developing the initial plan of care. Maintains productive and professional relations with external agencies and healthcare providers. Assumes responsibility for the effective and professional delivery of health services Confirms scheduled visit(s) in advance based on prioritized judgment of case load needs. Prepares for visits, anticipates care needs, reviews referral information, and obtains needed materials and educational resources for patients/caregiver. Makes visits to provide evaluation of appropriateness for hospice care. Follows established admission procedure including completing consents for service, medication evaluation, symptom management, teaching, and documentation. Provides interventions under the direction of a physician. Identifies new problems or needs at the admission visit. Facilitates patient and caregiver independence to the extent possible. Stores all supplies safely and ensures that the work area is clean, secure, and well-maintained. Applies principles of infection control and ensures universal precautions in accordance with accepted professional practice. Maintains appropriate utilization of resources to ensure cost-effective delivery of healthcare. Plans workday to respond to priorities as well as to minimize travel time. When providing hospice care, appropriately utilizes VIA Health Partners patient related protocols, standing orders and guidelines including Hospice Pharmacia MUGs; criteria for oxygen use and other specialized treatments. Coordinates with Physician of the Day (POD) to ensure patient eligibility and provide assessment findings for physician to complete the Initial Narrative Certification of Terminal Illness, as applicable. Assumes responsibility for conducting effective patient and caregiver education at time of admission Identifies learning needs of patients and caregivers and provides necessary instruction. Demonstrates nursing care procedures. Utilizes teaching materials, tools, and written information appropriately. Encourages and allows time for questions and consultation. If admitting a patient in a HART facility, provides education to facility staff as needed. Collaborate with assigned VIA Health Partners Medical Social Worker all identified patient/caregiver psychosocial needs at initial interdisciplinary care plan development. Ensures accurate, complete and timely clinical documentation in accordance with VIA Health Partners guidelines Keeps clinical records current by synchronizing laptop information several times a day. Completes and submits all clinical documentation per VIA Health Partners clinical documentation guidelines. Initiates and maintains current medication profile as directed by physician. Documents medication teaching: purpose, dose, route, frequency, actions, indication for use, side effects and interactions. Communicates and coordinates with Hospice Pharmacia appropriate medications and relatedness to terminal illness. Records time/mileage report logs accurately via electronic medical record. Effectively initiates Nursing Assistant care plan All Nursing Assistant care plans shall be developed in accordance with the needs of the individual patient and within the Nursing Assistant scope of practice. The Nursing Assistant care plan will be submitted to the appropriate administrative assistant for communication to the team the next business day after admission. Assumes responsibility for establishing and maintaining effective working relationships with interdisciplinary teams and interdepartmental staff Attends and participates in meetings as assigned. Participates actively in process improvement. Maintains open lines of communication with Supervisor. Keeps Supervisor apprised of any complex patient/caregiver issues. Assumes responsibility for related duties as required or assigned Ensures that VIA Health Partners professional reputation is maintained and projected. Assumes responsibility for professional development and staying abreast of current trends in the healthcare field. Incorporates new information and methods into practice. Maintains current professional licensure, CPR certification and CEU requirements. Understands that physicians offices, hospitals, assisted living communities and nursing homes are our customers and strives for a positive and productive relationship. May perform other duties as required. Qualification Requirements To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Minimum Qualifications A Diploma or Associates Degree in nursing required; Bachelors Degree preferred. Current, active, and unrestricted NC/SC license as Registered Nurse (RN). Current CPR required; CHPN preferred. Oncology nurse certification if required for chemotherapy administration. Minimum 2 years related experience. Experience in direct care of patients with life limiting illnesses required. Related experience may include hospice and palliative care; family medicine; internal medicine; geriatrics, oncology; home health care; medical surgical. Prior experience in working in an environment which focuses on the pediatric population is required for Kids Path Nurse with BCLS (CPR) training for both adult and child/infant required. Computer proficiency is required.