Job Description

This is a full-time professional position. This position is part of the Transitions Kids (TK) interdisciplinary team and is responsible for developing and implementing appropriate care plans and interventions based on the goals of the patient and family, and in coordination with the patient’s care team. This position includes after-hours coverage and/or visits via telehealth and/or to patients’ homes to provide symptom relief and/or support at the time of a patient’s death during any assigned after-hours shifts. All work will be performed in a manner consistent with agency, discipline, and regulatory standards and regulations. The schedule for this position is Monday-Friday 8:30am-5:00pm; PRN weekends and holidays.

Responsibilities - what you do

• Provide medical and emotional support for families across the continuum of care, including during times of crisis.
• Collaborate with the Interdisciplinary Group (IDG) to assess, establish, and support the achievement of patient/family-centered care goals; to determine the patient’s level of care; and to coordinate the appropriate utilization of services.
• Use professional judgment, in collaboration with the IDG, to individualize the plan of care based on the interdisciplinary team’s assessment of the patient and family’s unique needs and response to care.
• Provide immediate and long-term assessment and documentation of the needs of patients and families enrolled in the TK program.
• Plan, provide, supervise, and document safe, competent, and compassionate care for patients in accordance with physician orders and established policies and procedures.
• Collaborate with the patient, the patient’s family, facility staff, and the TK team to develop culturally sensitive care plan components.
• Identify and make referrals to appropriate organizations in the community.
• Provide and document provision of appropriate and relevant end of life information and education to facility staff, patients, and their families in compliance with current Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoPs).
• Monitor and coordinate with Administrative Team to manage the appropriate use of patients’ medical equipment, supplies, and medications.
• Delegate tasks and supervises the activities of LPNs and Hospice Aides, as needed.
• Follow current CoPs as related to Certified Nursing Assistant (CNA) supervision.
• Provide coverage of after-hours phone calls from patients and families and/or after-hours visits to patient homes when needed and as arranged with supervisor.
• Contact DME companies, pharmacies, transportation services, and other related community entities involved in care of patient as needed.
• Professionally manage time, people, and technology.
• Participate in Transitions Kids team meetings.
• Participate in own professional development by maintaining required competencies, identifying learning needs, and seeking appropriate assistance or educational offerings.
• Actively participate in the orientation and training of new employees and students in all disciplines.
• Maintain current training and knowledge of pediatric nursing practices and pediatric hospice/palliative nursing.
• Perform other duties as assigned by Transitions Kids Director and/or Team Lead.

Expectations how you do it

• Model professionalism and empathy by consistently demonstrating compassion, respect, teamwork, and dedication in all interactions with coworkers, customers, and partners.
• Adhere to all TL policies, procedures, and organizational guidelines, ensuring compliance in daily work and decision‑making.
• Deliver care and services in accordance with ACHC Standards and Medicare Conditions of Participation when applicable to your role.
• Comply with all relevant state and federal laws, regulations, and professional standards within your defined scope of responsibility.
• Promptly communicate concerns, issues, or potential risks to your immediate supervisor or another member of the management team to support a safe and effective work environment

Requirements - what you need

• Registered Nurse with current NC license; BSN required.
• Minimum 2 years recent pediatric clinical experience required. Pediatric hospice, pediatric hospital inpatient, and/or pediatric home health experience or equivalent preferred.
• Pediatric Hospice and Palliative Care Nurse Certification (CHPPN) preferred.
• Bilingual preferred, particularly Spanish.
• Able to forge high-quality, trusting relationships with patients, families, and co-workers.
• Able to independently seek out resources and to work collaboratively with a team.
• Able to communicate clearly with patients, families, visitors, IDG team, physicians, facility staff, leadership, and others.
• Able to educate patients and families regarding Transitions Kids services and roll and to collaborate with patients and families to identify their goals and values that will inform medical decision-making. Experience engaging with patients and families in goals of care conversations and/or completing advance directives preferred.
• Able to teach patients and families in accordance with the plan of care.
• Knowledgeable about reimbursement sources, Medicaid regulations, licensing laws, and accreditation standards.
• Competent computer skills with ability to learn new software programs.
• Current CPR certification.
• Must have and maintain a valid North Carolina Driver’s License, maintain automobile insurance coverage, and have access to reliable transportation.
• Must be able to travel to, enter and function in the homes/facility of any patient/family in the service area to assess and provide care to all patients.
• May be required to lift and/or carry items up to 50 pounds.
• Must have sensory abilities to complete physical assessment, communicate with patient/family care providers and physician, and to complete the reporting and follow-up documentation responsibilities of the job.
• Available to work during regular business hours (0830-1700 Mon-Fri) and scheduled hours with weekend and holiday commitments as outlined in Employee Information Agreement.