Job Profile Summary 

​This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders.  In addition, this role focuses on performing the following Home Care Nurse duties: Assesses, plans, implements, and evaluates the care needs of a designated group of patients or provides nursing care and identified clinical support tasks within the scope of practice for achievement of the patient’s plan of care as directed.  Provides professional nursing care to patients. Requires a nursing license.   A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs.  The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education.   An experienced level role that applies practical knowledge of job area typically obtained through advanced education and work experience.  Works independently with general supervision, problems faced are difficult but typically not complex, and may influence others within the job area through explanation of facts, policies and practices. 

Job Overview 

The position is a member of the hospice staff who determines appropriateness of referrals, coordinates and conducts pre-admission activities, completes admission when determined hospice appropriate, monitors inpatient care at contracted hospitals, performs in-service training and community education activities. This position performs duties in a variety of settings including 6patient’s home, acute care setting, skilled nursing facility or assisted living. 

Job Description 

Minimum Qualifications: 

1. Massachusetts RN Licensure. 

2. Hospice and/or end of life experience required. 

Location: Lowell, MA and surrounding areas

Hours: Full-Time, 40hrs/week, Weekend/Holiday Commitment.

Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list.  Other duties and responsibilities may be assigned. 

1. Describes and explains hospice services to a potential patient and/or family member and elicits responses to questions regarding attitude towards hospice care, evaluates physical and psycho/social/emotional status, in order to put the patient and family at ease about choosing hospice and fully inform them about the program.  

2. Works with hospice intake and eligibility department to verify insurance reimbursement for each referred patient and document in EMR. 

3. Reviews and explains to patient and/or family about insurance coverage and financial obligations, using knowledge of hospice fees, costs and reimbursement sources. Escalates to referral management director and/or referral manager, in circumstances of potential admission where reimbursement sources appear not to cover hospice fees, to ascertain whether reduce fee or free care may be offered.  

4. Introduces and explains benefits of hospice care and familiarizes decision makers with characteristics and needs that indicate an appropriate hospice referral. Presents the advantage of the hospice Medicare/Medicaid benefits to referral sources. 

5. Thoroughly understands the Medicare/Medicaid hospice benefit, the Medicare home health benefit, the Medicare/Medicaid long term benefit and the Medicare HMO benefit. 

6. Documents a narrative note in the EMR summarizing pertinent physical and psychosocial information from the hospital record and/or from the physician and patient/family assessment. Reviews referred patient’s history, medical status, and prognosis to determine eligibility for hospice services relying on the knowledge of hospital procedure and hospice admission criteria. 

7. Completes the patient/family admission packet, including obtaining signed Notice of Election of Hospice Benefit (NOE), admission forms from the patient, family, referral source and the attending physician. Uploading completed admission documents electronically to medical records for them to complete their process. 

8. Communicates information from Comprehensive Assessment to TMCAH CMO, hospice physician or TMCAH covering NP. Documents results and performs warm hand off to team. 

9. Communicates NTUC to appropriate staff and managers. Documents reason and continuation of care measures implemented. 

10. Promotes hospice services, to ensure appropriate referrals to hospice program, may perform liaison activities centered in the acute care setting, which include but not limited to, case conferences to case managers, discharge planners, physicians, other health care providers and referral sources. 

11. Works with TMCAH liaison and intake staff to ensure ease of referral, as well as a rapid response to the referral source. 

12. Evaluates and compares information, regarding referred patient to hospice criteria. Consult with either the referral management director, referral manager, CMO, or hospice physician when an admission is questionable.  

13. Communicates on a regular basis with patient, family, referral source, hospice intake or liaison staff, to ensure continuity of care and adherence to the hospice plan of care.  

14. Develops opportunities for and conducts in-service presentations in health care facilities regarding hospice care and the indications for a hospice referral. 

15. Promotes knowledge and awareness of the hospice program and its services to the professional community. 

16. Identifies potential new referral sources. 

17. Joins approved professional organizations and other groups which include key decision makers in the care of terminally ill patients. 

18. Assists with public relations activities to promote community awareness of Hospice services.  Includes activities during National Hospice Month. 

19. Reports Compliance concerns to the CEO or Chief Compliance Officer when applicable. 

20. Ensures compliance within guidelines set forth by regulatory agencies (DPH, ERISA etc.) and demonstrates compliance with Tufts Medicine Care at Home policies and procedures. 

21. Gathers all pertinent information necessary for admission. 

Physical Requirements:  

1. While performing the duties of this job, the employee is required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; taste or smell. 

2. The employee must regularly lift and/or move 25 lbs and occasionally lift and/or move up to 100 lbs. 

3. The employee in this position frequently communicates internally and externally. 

4. Must be able to exchange accurate information via phone, email and/or in person. 

5. Specific vision abilities apply including close vision, distance vision and ability to adjust focus. 

6. Noise level in the work environment is usually moderate. 

7. May be exposed to weather conditions prevalent at the time. 

Skills & Abilities: 

1. Ability to effectively communicate with patients, families, physicians, and healthcare team. 

2. Ability to be organized and systematic. 

3. Knowledge of the home care practice setting.

What We Offer

• Competitive salaries & benefits

• Medical, Dental and Vision benefits start day one

• 403(b) retirement with company match

• Tuition reimbursement and continuing education support - Access to MedBridge for PT CEUs and licensure/certification support, reinforcing our commitment to ongoing clinical development.

• Opportunities for career growth

• Fleet car program - A unique offering that reduces personal vehicle burden and supports clinicians in the field.

• Industry-Leading Safety Program – A one-of-a-kind Workplace Safety & Violence Prevention role dedicated to proactively addressing increasing safety concerns in healthcare settings. This program includes:

  • AVADE de-escalation and self-safety training

  • InvisaWear GPS-enabled safety devices

  • Escort services to ensure staff safety in the field

About Care at Home:

Tufts Medicine Care at Home is a proud member of Tufts Medicine, a health system that is rethinking how academic and community centers, local and national businesses, and technology and service innovators can all work together. So that clinicians can deliver expert care where it’s needed most and so that we can bring wellness back to health care, one person at a time. 

About Tufts Medicine 

A healthcare system that works Tufts Medicine is more than a health system — we’re a community that empowers people to live their best lives by reimagining healthcare, advancing knowledge and pioneering discovery. Every team member plays an integral role in realizing our vision of creating the most equitable and frictionless healthcare experience in the world. Here, you’ll join an enthusiastic community that champions your growth and receive generous benefits to support you and your family’s well-being. 

Tufts Medicine is an equal opportunity employer