Registered Nurse (RN) - Hospice Care Coordinator
Department Hospice
Contact Torud, Karen R.
Location La Crosse
Schedule/Shift Day/Weekend/Call Hours
Benefit Eligible Yes
Temporary Position No
Job Details

RN, Care Coordinator - Hospice


This is a full-time, salaried position within the Hospice Department.


72 hours every two weeks, approximately 8 shifts every two weeks


Position requires travel within the hospice service area encompassing a 50 mile radius of La Crosse, Wisconsin. 


RN licensure required to work in the state of Wisconsin and Minnesota. 


Daytime hours with rotating every third weekend, holiday coverage and on-call coverage for some evening and night shifts.

Purpose: As an advocate for the patient, the RN, Care Coordinator (RN-CC) assists patients to reach optimal function and health in an appropriate environment that would support their needs.

Role Definition: The RN-CC functions within the full scope of nursing practice to include the major responsibilities of the position description and to extend those responsibilities beyond the episode of care to encompass coordination of care across the continuum. The continuum of care includes inpatient to outpatient to community. The length of time an RN-CC would follow a patient is determined by patient needs and attainment of mutual goals.

The RN-CC applies the process of assessment, planning, implementation, monitoring, evaluation and coordination of care to meet the patient's health care needs across the continuum in collaboration with health team members to ensure safe, quality and cost effective care.

The RN-CC meets the expectations of a professional employee. The RN-CC collaborates with the health care team to assist the patient towards their highest level of functioning. Assists the patient and family in navigating their health care needs throughout the continuum of care.

Job Responsibilities
  • Patient Information Analysis:

    • Uses assessment skills and appropriate risk assessment tools to identify patients with actual or potential health care needs that would require care coordination.
    • Collaborates with patient/family in establishing mutual goals based on the patient's needs or problems.
    • Evaluates, compares and interprets ambiguous and changing patient data.
    • Explores patient's understanding and knowledge of current health status.
  • Patient observation and monitoring:

    • Applies nursing judgment to determine level of care assigned or delegated.
    • Uses knowledge of complex physiology to monitor, detect and anticipate early and subtle health status changes.
    • Monitors, trends and records patient response to disease, illness, treatment.
  • Nursing Action:

    • Coordinates care across the continuum (inpatient/outpatient/community) to assure appropriate utilization of clinical and community resources.
    • Accountable for individualized plan of care and its delivery.

    a)  Applies expertise to solve problems, generate ideas, plan care, teach and create new services.
    b)  Assigns Standards of Care
    c)  Uses scientific background, knowledge of change theory, ability to work with an interdisciplinary team, psychosocial skills and creative strategies to ensure quality, effective, evidence based and cost efficient care for the patient.
    d)  Collaborates with patients about plan of care.
    e)  Guides development of multiple health care partnerships to achieve a positive health effect.

    • Maintains purposeful therapeutic presence with patients based on nursing judgment.
    • Provides care based on patient complexity and nursing judgment.
    • Uses patient's perspective to support informed decision-making.
  • Promotes patient wellness and facilitates healing.

    • Anticipates future needs and educates or refers to valid sources of information.
    • Understands the patient's unique perspective and assures right education, right time, right environment for learning.
    • Evaluates outcome of learning.
  • Delegation and supervision of assistive personnel.

    • Delegates care based on situation.
    • Fosters teamwork and respect.
    • Assures effective use of staffing resources.
    • Supports assistive personnel:  Serves as a resource and holds assistive personnel accountable to complete delegated tasks.
  • Professional expectations:

    • Ascribes to the ANA Code of Ethics for professional nursing practice.
    • Commits to culturally congruent care.
    • Commits to continuous learning.
    • Participates in education of nursing colleagues and students.
    • Commits to evidence-based practice and the conduct of nursing research.
    • Commits to mission, vision and values of organization and to the profession of nursing.
  • Patient agent responsibilities:

    • Creates an environment that assures patient safety.
    • Promotes healing by creating an environment that conserves patient energy.
    • Instills confidence in the patient's own ability to regain/optimize their own health.
    • Partners with patient to help them integrate health status changes into their life.
  • Quality Improvement & Outcome Activities

    • Continually evaluates the data to further refine the referral criteria to the RN CC caseload; provides feedback to staff to improve the referral process.
    • Identifies actual or potential variances in standards of care and system problems that could lead to errors, delays in care, complications or increased cost.
    • When appropriate, integrate care coordination with disease management efforts to achieve low cost interventions that achieve the greatest benefit and increase the accountability of patients for management of their disease.

  • Scope of the Job
    Age Specific Population Served Pediatric (1 - 12 years)
    Adult (18 - 64 years)
    Unit/Department Specific
    Geriatric (65 years & older)
    Adolescent (13 - 17 years)
    Infant (less than 1 year)
    OSHA Category Category I - All Employees in this job title have a reasonably anticipated risk of occupational exposure to blood and/or other potentially infectious materials.
    Position Qualifications
    Education and Experience:
    Required Associate degree in   Nursing from an accredited college of nursing, as recognized by the Accreditation Commission for Education in Nursing (ACEN) or Commission on Collegiate Nursing Education (CCNE). Registered nurses without a baccalaureate degree will be required to get a Bachelor's degree in Nursing from an accredited nursing program (ACEN or CCNE) within six years of hire date. Graduates from nursing programs which are not accredited by ACEN or CCNE, must have at least one year of recent RN experience from an applicable care setting. 
    Desired Bachelor's degree in  Nursing from an accredited college of nursing, as recognized by the Accreditation Commission for Education in Nursing or Commission on Collegiate Nursing Education, such as Clinical Nurse Leader or related healthcare field. 

    Work Experience:
    Required 3-4 years  of RN experience in nursing for Hospice care coordinator positions and 5 to 7 years of experience for Care Coordination care coordinator positions
    Required Ability to...
    Computer Systems/Software/Applications basic computer skills
    Communication demonstrate effective customer service to internal and external customers
    Communication express or exchange ideas by means of the spoken word, communicating orally with others
    Comprehension understand complex problems and to collaborate and explore alternative solutions
    General - All Positions demonstrate commitment to quality and attention to detail
    General - All Positions conceptualize, think abstractly and continuously learn
    General - All Positions work as part of a team
    General - All Positions anticipate, think and respond quickly
    General - All Positions be flexible and adaptable
    General - Patient Care apply expert professional nursing knowledge
    General - Patient Care complete clinically-appropriate and timely documentation
    Leadership delegate
    Mathematics add, subtract, multiply, divide, record, balance, and check results for accuracy
    Organization organize and prioritize work schedules of others on short-term basis
    Organization time management skills
    Reasoning/Decision Making make decisions which have significant impact on the department's credibility, operations and services
    Desired Ability to...
    License and Certifications
    Required Registered Nurse (RN) licensed to practice in the state of employment, some positions may require multiple licenses and 
    Current American Heart Association (AHA) Healthcare Provider CPR certification; Heart Saver, Rescue and Military training network CPR; or the American Red Cross CPR certification (CPR) except Citizen and Animal classes 
    Desired RN Specialty Certification 
    Physical Requirements/Demands of the Position
    Sitting Frequently (34-66% or 5.5 hours)
    Static Standing Continually (67-100% or 8 hours)
    Walking/Standing Continually (67-100% or 8 hours)
    Driving Never (0%)
    Stooping/Bending Occasionally (6-33% or 3 hours)
    Squatting Occasionally (6-33% or 3 hours)
    Kneeling/Half Kneel Occasionally (6-33% or 3 hours)
    Climbing Stair Occasionally (6-33% or 3 hours)
    Climbing Ladder Never (0%)
    Reaching - Shoulder Level Continually (67-100% or 8 hours)
    Reaching - Below Shoulder Continually (67-100% or 8 hours)
    Reaching - Above Shoulder Occasionally (6-33% or 3 hours)
    Repetitive Actions - Pinch Forces Pounds of force:
    Repetitive Actions - Grip Forces Pounds of force:
    Repetitive Actions - Fine Manipulation Frequently (34-66% or 5.5 hours)
    Balance - Right Leg
    Balance - Left Leg
    Lifting - Floor to Waist Number of lbs:
    Lifting - Waist to Overhead Number of lbs:
    Lifting - Other Occasionally (6-33% or 3 hours) Number of lbs:
    Carrying - Long Carry (>50 feet) Number of lbs:
    Carrying - Short Carry Number of lbs:
    Carrying - Right Carry Number of lbs:
    Carrying - Left Carry Number of lbs:
    Carrying - Push/Pull (Static Force) Number of lbs:
    Number of lbs:
    Environmental Conditions
    Exposed to infectious diseases.

    Registered Nurse (RN) - Hospice Care Coordinator

    Equal Opportunity Employer