Continuity of Care RN- FT
Elkhart, IN
Job Description


You're more than a Continuity of Care RN at AseraCare Hospice. With your vast experience, you know quality care and that's why we've entrusted you to join together with a team of spiritual care coordinators, social workers and counselors. That's because we know you'll go to any length for our patients during their end-of-life journeys. You'll ensure patients receive care on a variety of levels because at AseraCare Hospice, we consider the whole patient. That's why you'll participate in our interdisciplinary approach while simultaneously leading by example and setting only the highest standards. You'll engage with the patient's entire family to help them and other caregivers understand and support the process. You'll see your impact in this highly valuable role every day, as you adjust to new working environments and make a profound difference in the lives you touch. We are looking for qualified and compassionate candidates with considerable nursing experience. You are independent, flexible, a leader and ready to inspire our talented medical professionals to uphold our promise of quality care.


The Continuity of Care RN Nurse responds to calls from patients, families, caregivers, and referral sources. The nurse assesses, utilizes critical thinking and gives advice or delivers care to patients utilizing the nursing process of assessment, planning, interventions, implementation, and evaluation; and effectively interacts with patients, significant others, and other interdisciplinary team members while maintaining standards of professional nursing and clinical competency.


  • Responding to calls from Triage Center and Triaging patient related calls by determining the needs of the caller and then responding in an appropriate manner either by phone or with a visit.
  • Implementing changes to the plan of care as needed with interdisciplinary collaboration with the support of the hospice medical director and / or the attending physician.
  • Documenting and communicating all calls, interventions, care plan changes, physician contacts in a manner consistent with policy and procedure. Documenting accurate assessment of patient status and updating the plan of care utilizing appropriate communication (verbal, electronic, written, email documents and databases). Document at time of patient visit or admission the patient care reflecting nursing interventions, patient response to care, focusing on the patient's goals.
  • Assisting patients, family members or caregivers with concern and empathy; respect confidentiality and privacy and communicate in a courteous and respectful manner.
  • Attending patient deaths to provide support to the patient's family, in a manner consistent with policy and procedure. Provide bereavement resources to the family as appropriate.
  • Responding to referrals calls, providing the caller with information regarding hospice care, screening calls for appropriateness, taking patient information.
  • Performing patient admission visits in a manner consistent with policy and procedure and communication of new patient status to the team.
  • Maximize non-patient care time by completing chart audits, facility medication reviews, facility record audits and enhance hospice awareness in the community through family meetings, collaboration meetings and in-services.


  • Must adhere to the Company's Code of Conduct and Business Ethics policy including documentation and reporting responsibilities.


  • Graduate of an accredited school of nursing.
  • Valid license as a Registered Nurse in the State of employment
  • Preferably a minimum one (1-2) years-experience in hospice, home health, or community health
  • Must have current certification for CPR
  • Minimum one year recent professional nursing experience
  • Computer skills including Electronic Medical Records and E-mail
  • Must be available nights, weekends and holidays
  • Must be a licensed driver with a reliable automobile that is insured in accordance with state and/or organization requirements
  • Must demonstrate a commitment to the hospice philosophy of care
  • Must be capable of maintaining regular attendance
  • Sensitive to the needs of patients with advanced illness and families and one's own feelings about dying and death.


  • Must be knowledgeable of Medicare hospice certification
  • Must demonstrate excellent observation, nursing judgment and communication skills.
  • Must possess the ability to provide good written documentation in a timely manner
  • Must be self-directed with the ability to work with minimal supervision
  • Must be able to maintain confidentiality regarding patient and company proprietary information
  • Must possess computer skills of the types and at a level necessary to accomplish the job
  • Must have excellent interpersonal communication
  • Must have the ability to relate professionally and positively and work cooperatively with patients, families, and other employees at all levels and be able to cope with emotional stress and be tolerant of individual lifestyles


  • Mobility, reaching, bending, lifting (minimum of 10 pounds), fine hand coordination, ability to read and write, the ability to understand and follow written and oral instructions and directions, ability to travel, and ability to remain calm under pressure
  • Staff may be exposed to virus, disease and infection from patients and specimens in working environment.
  • Staff will be required to work in patient's homes and be responsible for own transportation.
  • Staff may experience traumatic situations in the family setting


Golden Living and AseraCare Hospice are committed to enhancing the lives of the patients we care for. Here, you'll find some of the best professionals in healthcare working together to provide the highest level of care to every patient and resident we serve. And, we're able to offer career opportunities that fit almost anyone's background or level of experience. From where you work to how you work to everything in between, we're confident that at Golden Living and AseraCare Hospice, you'll find exactly what you're looking for in your career.

Job Type Full-time