Supportive Palliative Care Nurse TCM

Supportive Palliative Care Nurse (RN/LVN)

Department: Clinical Operations
Reports To: Director of Clinical Services / Clinical Manager
FLSA Status: Non-Exempt (or Exempt based on structure)
Location: Hybrid / Remote / Office-Based (as applicable)
Position Type: Full-Time / Part-Time / PRN

Position Summary

The Supportive Palliative Care Nurse serves as a clinical liaison and care coordinator for patients transitioning from hospitals, facilities, physician referrals, and community settings into the Supportive Palliative Care Program. This role focuses on telephonic patient engagement, symptom support, care coordination, education, and helping patients successfully transition into outpatient palliative services.

The nurse acts as a supportive clinical resource to improve patient outcomes, reduce avoidable hospital utilization, and ensure patients receive timely, compassionate, goal-focused care.

Essential Duties & ResponsibilitiesTransition of Care Management

• Receive and review patient referrals from hospitals, providers, facilities, and internal sources.
• Conduct outbound transition calls to recently discharged patients and caregivers.
• Complete initial telephonic nursing assessments and identify immediate patient needs.
• Facilitate smooth transition from acute care settings into supportive palliative care services.
• Coordinate follow-up appointments and service initiation.

Patient Outreach & Engagement

• Maintain consistent communication with patients and families.
• Educate patients regarding supportive palliative care services and expectations.
• Assist patients in understanding disease progression and available support resources.
• Encourage engagement with providers and care plans.

Clinical Support

• Perform nursing triage and symptom discussions within scope of practice.
• Identify changes in condition and escalate concerns appropriately.
• Review medication concerns and support medication reconciliation efforts.
• Monitor for unmanaged symptoms including:
• Pain
• Shortness of breath
• Anxiety
• Fatigue
• Nausea
• Functional decline

Care Coordination

• Collaborate with physicians, nurse practitioners, social workers, hospitals, and interdisciplinary teams.
• Communicate updates and barriers to appropriate providers.
• Coordinate referrals for additional community or support services.
• Ensure continuity across transitions of care.

Documentation & Compliance

• Document all outreach, interventions, and patient communications in EMR.
• Maintain timely and accurate records.
• Follow HIPAA and confidentiality requirements.
• Participate in quality improvement and transition outcome tracking.

QualificationsRequired:

• Active Texas RN or LVN license in good standing.
• Minimum 2 years of nursing experience.
• Experience in one or more:
• Palliative Care
• Hospice
• Care Coordination
• Home Health
• Hospital Discharge Planning
• Case Management
• Chronic Disease Management
• Strong telephone communication skills.
• Ability to manage multiple patient transitions simultaneously.

Preferred:

• Experience in supportive or palliative care.
• Transition of Care (TOC) experience.
• Experience using EMR systems.
• Bilingual preferred.

Knowledge, Skills & Abilities

• Compassionate communication and patient-centered approach.
• Strong assessment and critical thinking skills.
• Excellent organization and follow-through.
• Ability to build rapport quickly by phone.
• Ability to educate and motivate patients and families.
• Understanding of serious illness management and supportive care principles.

Performance Metrics (Suggested KPIs)

• Transition outreach completed within target timeframe.
• Referral conversion to active enrollment.
• Patient engagement rate.
• Follow-up completion rate.
• Documentation compliance.
• Patient satisfaction scores.
• Hospital readmission reduction support.

Mission Alignment

We provide compassionate, supportive care focused on improving quality of life, easing symptom burden, and helping patients navigate serious illness with dignity and confidence.

Pay: $47,225.62 - $56,873.86 per year

Work Location: In person