Lead Hospice GIP RN

Newport News, Virginia

This is not a routine nursing role; it’s a leadership opportunity at the heart of some of the most meaningful care we provide.

As the Lead Hospice GIP Nurse for Riverside At Home, you will be the trusted clinical presence guiding patients and families through some of life’s most critical moments. Based at Riverside Regional Medical Center, the largest and most dynamic regional medical center in Hampton Roads, you’ll serve as the face of Riverside At Home, helping ensure that very sick patients are matched with the right level of care, at the right time, in the right setting.

You’ll work shoulder-to-shoulder with care managers, discharge planners, physicians, and palliative care teams to identify appropriate referrals and coordinate smooth, compassionate transitions across acute care, long-term care, assisted living, home, and General Inpatient Hospice (GIP) services. This role blends strong clinical judgment, leadership, and hands-on bedside nursing.

Performs coordination of services to provide a seamless transition from acute and long term care to Home Care. Elements required for above include data collection and clinical review of all referrals; determination of referral acceptance based on established criteria and collaboration with Home Care team members; attaining and remaining knowledgeable and current related to Medicare/Insurance reimbursement and basic coverage criteria, and of service lines and products;

and conferencing with patients, families, DC planners, physicians, medical staff and others to coordinate and facilitate transition and services. Works closely with facility care management/DC planners to identify potential referrals for Home Care Services. Provides exceptional customer service and serves as the face of RHCD to all contacts by telephone, in person and via electronic media. Provides leadership to and supervision for the RHCD Patient Transition Coordinators.

• Performs coordination of services to provide a seamless transition from acute and long-term care to Home Care. Completes clinical review of data collected and accurately determines appropriateness and acceptance of referrals based on established criteria. Coordinates services and dissemination of information, and facilitates transfer of referral to other agency for referrals declined by RHCD. Performs any follow up and continues communication with all parties until referral is complete and/or services are provided or canceled.
• Serves as an information resource for all RHCD services including contact information, coverage criteria, availability of services and alternatives to RHCD services when appropriate. Provides exceptional customer service by tone of voice, willingness to help, using clinical knowledge to collect complete and appropriate data for referrals, and to field phone calls/pages/in-person inquiries efficiently and appropriately.
• Accurately and efficiently enters data into and retrieves data from various computer systems. Accurately and efficiently records data to specified RHCD forms.
• Works closely with care management team/discharge planners to identify potential referrals for RHCD services.
• Builds comprehensive knowledge base, and continuously works toward remaining knowledgeable and current of Medicare/Insurance information and regulations, RHCD products and services and community resources. Assists Central Intake Manager with review, updating and creation of policies, procedures and processes as needed.
• Performs patient interviews and or family conferences to inform of ordered services, verify demographics, answer any questions, discuss insurance coverage as appropriate, discuss any special circumstances or barriers to a safe transition or care at home as appropriate.

• Program Graduate, Nursing (Required)
• Associates Degree, Sociology/Social Work/Nursing (Required)
• Bachelors Degree, Sociology/Social Work/Nursing (Preferred)

• 1 year Nursing experience (Required)
• Home health experience (Preferred)
• Case management and health care delivery experience (Preferred)

• Registered Nurse (RN) - Virginia Department of Health Professions (VDHP) (Required)
• CPR/BLS Certification - American Heart Association/American Red Cross/American Safety and Health Institute (AHA/ARC) within 30 Days (Required)
• Clinical Social Worker (Preferred)

To learn more about being a team member with Riverside Health System visit us at