Supportive Care, RN

ChenMed; Lakeland North (WA); On-site; USD 85,000 - 120,000; Full time

Job summary

chenmed is expanding its primary care team and seeks an experienced Supportive Care RN to provide clinical and operational care for the serious illness management panel. You will perform comprehensive home, center, or facility assessments and coordinate care with the patient's PCP and specialists.

This role focuses on early identification of decline, symptom management at home, and guiding families through transitions of care, including hospice when appropriate, while maintaining strong

Qualifications

• Licensed RN with ability to conduct home and facility assessments.
• Experience in palliative or serious illness care is preferred.
• Strong communication and coordination with multi-disciplinary teams.

Responsibilities

• Perform comprehensive head-to-toe assessments across multiple systems.
• Collaborate with PCPs and specialists to coordinate care.
• Monitor patients remotely or in home/center settings and escalate when needed.
• Support transitions of care, including hospice referrals when appropriate.

Skills

ESAS-r

PPS

FRAIL Scale

ECOG

Tools

ESAS-r

PPS

FRAIL Scale

ECOG

Job description

We're unique. You should be, too.

We're changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy?

We're different than most primary care providers. We're rapidly expanding and we need great people to join our team.

The Supportive Care, RN is the clinical and operational care of patient engagement for the serious illness management panel in the market who need active palliative care involvement. Working alongside palliative care and specialty care team members, this position builds trust with patients facing serious, advanced illness; conducts comprehensive assessments in the home, center, or other facilities; monitors proactively for early signs of clinical deterioration; validates findings with the patient's PCP; coordinates care across specialists and care settings; and escalates to the Physician/NP when a case exceeds nurse-level management.

This role is essential to identifying decline early, managing symptoms at home, preventing unnecessary emergency department visits and hospitalizations, and helping patients and families navigate transitions of care - including, when appropriate, timely and compassionate hospice transitions that originate in the community rather than from a hospital bed.

ESSENTIAL JOB DUTIES/RESPONSIBILITIES:

Patient Identification, Outreach, and Enrollment

• Reviews daily all Tier 1/2 signals and specialist/PCP referrals, and complete first outreach within 48 hours.
• Reviews the patient's chart before first contact, including diagnosis, specialist contacts, recent hospitalizations, medications, and advance directives.
• Builds initial trust and rapport with newly identified patients and schedule the first home or center-based assessment visit.
• Coordinates scheduling of Palliative Care provider with specialty care team members.
• Obtains verbal consent by phone and written consent at the first visit; document preferred contact methods and caregiver information.
• Confirms and documents specialist contacts (oncology, cardiology, nephrology, pulmonology) and obtains releases of information; for oncology patients referred through the CPL partnership, confirm the co-management plan with the oncology practice.

Comprehensive Clinical Assessment

• Conducts head-to-toe assessments covering vital signs, neurological, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin/integument, pain, and functional status.
• Administers and scores validated clinical tools at each required interval: the Edmonton Symptom Assessment System (ESAS-r) at every visit, the Palliative Care Performance Scale (PPS) at every visit, the FRAIL Scale at initial assessment and every 90 days (or sooner with clinical change), and ECOG Performance Status at every visit.
• Complete detailed pain, nutrition and medication reviews, including a check of PRN medications available in the home, center or dwelling and confirmation the patient and caregiver know how to use them safely.
• Review and document goals of care, advance directive status, POLST/DNAR status, and healthcare surrogate or power of attorney designation at every visit; confirm family readiness before any hospice referral is transmitted.

Ongoing Monitoring and Visit Cadence

• Determine and adjust visit frequency - face to face visits, telehealth, or phone check-ins based on the patient's Tier assignment, ECOG grade, and ESAS score, following program guidelines.
• Maintain, at minimum, weekly contact with every Tier 1 patient (a non-negotiable cadence floor) and contact with every Tier 2 patient at least every 3-4 weeks, increasing frequency as clinical presentation requires.
• Assess whether a model-generated signal warrants escalation into the panel or a return to surveillance; a fired signal obligates an assessment, not an automatic enrollment.

Physician/NP Collaboration and Door 1 / Door 2 Escalation

• Recognize and act on the two defined escalation paths to the co-located Physician/NP: Door 1, when a PCP, specialist, or the National Medical Director directly requests a physician-level consult; and Door 2, when the Serious Illness Care Guide own escalation criteria are met - a Tier 1 symptom unlikely to resolve at nurse level, a controlled-substance or complex prescribing decision, or a suspected hospice-eligibility determination.
• Communicate clinical changes, medication concerns, symptom scores, and goals-of-care updates to the Physician/NP and the patient's PCP promptly, accurately, and completely.
• Function within licensed scope of practice and applicable state regulations at all times; elevate rather than independently manage changes that require physician direction. No AI tier, score, or trigger alone routes a case to the physician - only Door 1 or Door 2.

Care Coordination and Transitions of Care

• Manage the full arc of any hospital admission for an enrolled patient: same-day detection, in-hosp