Welcome page Returning Candidate? Log back in! RN- Hospice Transitions - Admin RN Job Locations US-IL-Springfield ID 2025-29384 Category Registered Nurse (RN) (Experienced) Position Type Full-Time Min USD $32.95/Hr. Max USD $52.73/Hr. Overview

The Hospice Transitions RN, as a member of the Advanced Care Management department, identifies, assesses, and prepares hospitalized patients and their loved ones for the transition to end-of- care. Coordinates the discharge plan, problem solves, and documents actions and plans while collaborating, consulting, and advocating on the patient’s behalf. Holding continuity of care as a priority, communicates and coordinates with the larger healthcare team including the hospitalist, nurse, patient care facilitator, social worker, and palliative care.  Receives and follows up on hospice referrals by meeting with the patient/family, introducing hospice services, evaluating the patient’s status, eliciting choice for post-acute providers, facilitating orders, and anticipating needs for equipment, medication, and transportation

Qualifications

Education:

Graduate of an accredited College of Nursing, with a Bachelor’s degree required.

 

Licensure/Certification/Registry:

IL Licensed Registered Nurse required.CPR Certification required.

 

Experience:

Minimum three (3) years in nursing experience required.One (1) year experience in hospice or palliative care required.Experience in acute-care hospital setting; knowledge of discharge planning/case management preferred..

 

Other Knowledge/Skills/Abilities:

Must have clinical knowledge and critical thinking ability to create a viable and effective patient transition plan an identify barriers in service, effectively conduct verbal and written patient assessments, carry out the referral processes, and coordinate with other individuals involved in the plan of care.Understanding of home hospice services and regulations.Knowledgeable about disease states and prognosis and how illness progresses clinically and functionally.Self-starter with a high degree of initiativeAbility to work as part of a team as well as form harmonious working relationships with post-acute providersExcellent collaborative and problem solving skillsExcellent organizational skillsExcellent interpersonal and communication skillsStrong commitment to teamwork and patient experience Responsibilities Identifies, assesses, and prepares patients (and their families) for transition to home hospice careReviews hospital plan of care and current discharge planning effortsGathers additional information from the patient/family interviews, medical record, physicians, and other healthcare providersUnderstands current and future disease states and can accurately match patient’s needs to appropriate level of serviceFormulates a transition plan after reviewing available/appropriate care options and obtaining input from the patient/family, and the physician, healthcare team, and post-acute care providersIdentifies patient’s person-centered goals-of-care and provides education to the patient and family about home hospice’s line of services that would help meet those goalsIf needed, for hospice patients receiving General Inpatient Level of Care, assist with admissions and daily visits when directed, coordinate with the hospice Interdisciplinary teamMaintain accurate daily documentation including patient assessments, plans, interventions, patient/family involvement, coordination with physicians, colleagues, and post-acute care providers

 

Coordinates care, problem solves, and documents actions and plansUtilizes professional judgment to determine the need for a family meeting, escalation to leader, and other problem solving measuresMonitors transition plan and intervenes in an appropriate and timely manner with difficulties ariseIdentifies, communicates, and creatively develops efficient delivery of care as the patient moves to home hospice servicesEnters referral information and documents interactions in the appropriate electronic medical record

 

Collaborates, consults, and advocatesDevelops and maintains positive, productive relationships with colleaguesProvides educational opportunities in hospital, collaborating with peers and palliative care team as appropriateActively participates in rounds with other team members to effectively coordinate and facilitate transition plan

 

Adheres to departmental and organizational protocols, policies and procedures, and supports operational and strategic plans and objectives Demonstrates competencies related to service line knowledge, edibility criteria, regulations, and processesAdapts to changes in the work environment or work process in a timely, positive, and effective mannerDemonstrates a commitment to teamwork by willingly accepting responsibilities and performing assignments that support the teamCompletes all annual competency validation requirementsActively participates in department meetings and operationsIdentifies new systems or processes, protocol, and/or methods to improve practicesMaintains confidentiality of patient informationDemonstrates knowledge of appropriate utilization of internal and externa resources to meet patients’ needsEnsures quality standards are met. Follows all applicable licensure regulations and commonly accepted professional standards of practiceUtilizes time well to ensure follow-up is completed and needs of patient/family or healthcare providers are anticipated and proper plans are executed.

 

Performs other related work as required or requested.

 The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job.  Incumbents may be requested to perform tasks other than those specifically presented in this description.

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