Job Description

The schedule for this role is Monday-Friday 8:30 am to 5:00 pm, weekends and holidays TBD.

This is a full-time professional position. This position is a combination of direct clinical care, administrative tasks, employee supervision and education with broad responsibility for the day-to-day clinical, operational, and programmatic oversight of the GUIDE dementia care program. This position will coordinate with the Director of Serious Illness Services and the TMP Medical Director on project planning and implementation; program development and expansion; performing needs assessments and engaging in program building and expansion; and maintaining, creating, and updating processes to reflect the accepted standards of practice and ensure compliance on appropriate regulatory guidelines.

This position will provide direct nursing care -- RN position includes carrying a small caseload of patients. Position includes coordinating with hospital-based teams, collaborating and networking with community providers to participate in team and/or family meetings, and supporting referral sources in identification of appropriate referrals for Serious Illness, Palliative, Primary or dementia care services. Works closely with other TL team members to ensure quality of care and smooth transitions of care. This position also coordinates, plans, and provides ongoing education to external sources including referral sources and other community partners to advance and expand community awareness and mastery of palliative, hospice, dementia care and primary care. All work will be performed in a manner consistent with agency, nursing, and regulatory standards and regulations.

Responsibilities -

• Oversee daily clinical operations across the GUIDE dementia care program.
• Ensure plans of care align with patient goals and regulatory requirements.
• Provide direct nursing care including complex symptom assessment and advance care planning.
• Supervise RN Care Navigators and support GUIDE team members.
• Review, update, and create processes to enhance clinical operations and practices for ongoing quality improvement while also ensuring compliance with current Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoPs).
• Manage various personnel actions including, but not limited to hiring, orientation, performance appraisals, promotions, and scheduling; and counsel and conduct formal discipline of hospice and palliative team members.
• Plan, provide, supervise, and document in a timely and accurate manner medical and emotional support for geriatric patients and families significantly impacted by illness or loss across the continuum of care and in accordance with established policies and procedures, including during time of crisis, during admission to TL serious illness services, when functioning in direct care capacity, and during inpatient hospitalizations.

Expectations –

• Demonstrate professionalism, compassion, and leadership while adhering to regulatory and organizational standards.
• 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 (RN) with current NC license; BSN required.
• 3–5 years progressive clinical experience including CMS GUIDE or dementia care programs.
• Leadership experience including program management and team member oversight.

Environmental Factors

• Requires intermittent travel within 10 county service area.