Job Description

Position Purpose: Under general direction, the hospice nurse oversees, monitors, and coordinates the daily operations of Steward Health Care Network's (SHCN) Hospice care management/care coordination activities. The hospice nurse is a Subject Matter Expert at SHCN and works collaboratively with the care management team and other internal and external stakeholders. The Hospice Nurse is tasked with ensuring that care coordination to maintain optimal processes and procedures are visible throughout the network to to ensure high quality transitions for the right patient at the right time


• Coordinates and oversees the identification, evaluation and screening of potential hospice patients in the ACO.

• Helps identify ACO patients appropriate for hospice referrals, completion of screening assessments to facilitate transition. Ensures documentation of activities is captured in the appropriate system(s).

• Provides clinical guidance and counseling to patients and families to assist their decision about hospice services.

• Cooperates in continually improving performance using clinical best practices and data to improve performance.

• Meets regularly with treatment team to review cases and provide expertise about hospice eligibility.

• Communicates early and often with Providers/PCP to discuss appropriateness of hospice services.

• If Provider / PCP in agreement with hospice referral, coordinates accordingly.

• Works closely with Steward Hospice team to streamline screenings and referrals as appropriate.

• Works with non-Steward hospice agencies in appropriate situations

• Helps provide in services and education of staff to promote best practices and implementation of quality of care. Stays informed of changes in nursing and hospice practice and informs appropriate organizational personnel.

• Assists leadership in developing and growing the program strategy promoting hospice referrals in the community and coordinating with the clinical teams in the program.

• Collects data to assess program effectiveness.

• Assists in implementing care via agencies and evaluating clinical status and needs of the patient, family / caregiver care as indicated.

• Uses data to identify potential patients for screenings.

• Works collaboratively with the department leaders and the IT department to ensure the maintenance of care management databases and use of care management documentation systems. Proactive about identifying and advocating for system enhancements that may be required to deliver high quality care management services. Collaborates with IT teams to implement, test, and deploy system upgrades and enhancements.

• Maintains equipment and services agreements as needed.

• Responsible for assisting in the implementation of Care Improvement (LEAN) initiatives and principles related to achieving quality and patient satisfaction outcomes.

• Demonstrates professionalism that creates and fosters a culture of continuous improvement in the department.

• Performs all job functions in compliance with applicable federal, state, local, and company policies and procedures.

• Travel throughout the SHCN network for meetings with internal and external stakeholders

• Other duties as assigned.


• RN

• Minimum 4 year degree

Years of Experience:

• Minimum two to five years' experience in hospice role

Work Related Experience:

• Demonstrated ability to supervise and manage staff

• Knowledge of hospice governmental rules and regulations and ACHC standards

• Helping promote the hospice concept and growing programs

Specialized Knowledge:

• Excellent critical-thinking, observation, written /verbal skills, problem-solving, and analytical skills

• Ability to lead and motivate others to execute a plan in a rapidly changing environment

• Ability to work collaboratively with health care professionals at all levels to achieve established goals and improve quality outcomes.

• Strong current working knowledge of hospice; knowledge of Accountable Care Organization (ACO) desirable

• Knowledge of leading practice in clinical care and payer requirements.

• Familiarity with the compliance and regulatory standards governing health plans and patient care including NCQA, URAC, federal, state, and other regulatory requirements.

• Current State RN license

• Valid driver's license an insured vehicle in proper working order for local travel

• Ability to use Microsoft Office tools including Word PowerPoint, and Excel, EHR

Application Instructions

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