RN- Care Coordinator- Serious Illness Services, Full-...

Job Summary This is a full-time professional position providing nursing care coordination for patients enrolled in Serious Illness Services (including special programs, palliative care, and dementia care programs). This role includes direct patient and caregiver contact through a hybrid model of care, combining community-based visits, and telehealth encounters (phone or video). The Care Coordinator RN delivers education, assessment, and ongoing support based on individualized program guidelines and collaborates closely with interdisciplinary team members and referral sources. The schedule for this position is Monday–Friday, 8:30am–5:00pm; weekends and holidays TBD.Responsibilities — What You DoClinical & Care CoordinationProvide safe, competent, compassionate care and coordination to patients in Serious Illness Services, including those enrolled in the dementia care program. Conduct comprehensive in-home and telehealth assessments for patients, evaluating caregiver needs, home safety, behavioral symptoms, and disease progression. Deliver disease specific education, care planning, and ongoing coaching to caregivers. Triage phone calls for patients as needed to support Serious Illness Services. Provide appropriate end-of-life (EOL) information, anticipatory guidance, and education to patients, families, and hospital or facility staff as applicable. Interdisciplinary Collaboration & SupportSupport clinicians in the field regarding administrative and clinical coordination needs. Collaborate with MSWs and other interdisciplinary team members to coordinate care and facilitate visits across service lines. Participate actively in interdisciplinary team meetings. Assist in the transfer of patients and/or information between programs in collaboration with appropriate team members. Program & Administrative ResponsibilitiesEnsure all required dementia program documentation, tracking elements, assessments, and care plans are completed according to CMS guidelines. Provide information about available community resources, including dementia specific, disease specific support. Accurately document all contacts, assessments, and communications in the electronic medical record. Assist with data collection and reporting needs for Serious Illness and dementia care programs. Demonstrate willingness to cross train across service lines and support additional areas of clinical need. Perform other duties as assigned by the supervisor. Expectations — How You Do ItExemplify TL Core Values in all interactions with patients, families, colleagues, and referral sources. Demonstrate excellent customer service skills and positive, compassionate communication. Adhere to TL policies, procedures, and clinical guidelines. Follow CMS and state regulations, nursing standards of practice, NHPCO Ethical Practices, and the American Nurses Association’s Code of Ethics. Maintain confidentiality, professionalism, and clinical integrity in all aspects of care. Requirements — What You NeedRegistered Nurse with current NC license; BSN preferred. CHPN certification or willingness to complete certification within 2 years. At least 3 years of clinical experience; at least 2 years of home health, geriatrics, palliative care and/or hospice experience or equivalent. Experience with dementia care preferred; willingness to obtain dementia specific training required for program compliance. Excellent verbal and written communication skills. Ability to multitask and coordinate multiple complex clinical workflows. Proficient computer skills and comfort with telehealth platforms. Current CPR certification. Reliable transportation and the ability to travel to, enter, and function in patient homes and facilities across the service area. Valid North Carolina Driver’s License and maintained automobile insurance coverage. Ability to lift and/or carry items up to 35 pounds. Sensory abilities sufficient for physical assessment, communication, and accurate completion of documentation Keywords: care coordinator RN, dementia, geriatrics, palliative care Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.

Created: 2026-03-04