Job Summary

This is a full-time professional position. This position is part of the Transitions Kids (TK) interdisciplinary team and is responsible for developing and implementing appropriate care plans and interventions based on the goals of the patient and family, and in coordination with the patient’s care team. This position includes after-hours coverage and/or visits to patients’ homes to provide symptom relief and/or support at the time of a patient’s death during any assigned after-hours shifts. All work will be performed in a manner consistent with agency, discipline, and regulatory standards and regulations. The schedule for this position is Monday-Friday 8:00am-5:00pm.

Responsibilities - what you do

• Provide emotional support for families across the continuum of care, including during times of crisis.
• Collaborate with the Interdisciplinary Group (IDG) to assess, establish, and support the achievement of patient/family-centered care goals; to determine the patient’s level of care; and to coordinate the appropriate utilization of services.
• Provide immediate and long-term assessment and documentation of the needs of patients and families enrolled in the TK program.
• Plan, provide, supervise, and document safe, competent, and compassionate care for patients in accordance with physician orders and established policies and procedures.
• Use professional judgment, in collaboration with the IDG, to individualize the plan of care based on the interdisciplinary team’s assessment of the patient and family’s unique needs and response to care.
• Collaborate with the patient, the patient’s family, facility staff, and the TK team to develop culturally sensitive care plan components.
• Identify and make referrals to appropriate organizations in the community.
• Provide and document interventions to patients and families, to include the full range of sacraments and rituals of the patient and/or family’s spiritual/religious community if applicable to discipline.
• Participate in the creation and implementation of grief and bereavement services for TK patients and families in conjunction with other TK Pediatric Palliative Care Specialists – FS.
• Provide and document provision of appropriate and relevant end of life information and education to facility staff, patients and their families in compliance with current Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoPs).
• Participate in the identification of clinical or operational performance improvement opportunities and in performance improvement activities.
• Maintain current training and knowledge of applicable discipline.
• Participate in own professional development by maintaining required competencies, identifying learning needs, and seeking appropriate assistance or educational offerings.
• Responsible for professionally managing time, people and technology.
• Actively participate in the orientation and training of new employees and students in all disciplines.
• Provide coverage of after-hours phone calls from patients and families and/or after-hours visits to patient homes when needed and as arranged with supervisor.
• Participate in Transitions Kids team meetings.
• Perform other duties as assigned by Transitions Kids Program Manager and/or Team Lead.

Expectations - how you do it

• TK Core Values are exemplified in all interactions with internal and external customers.
• Adheres to TL and TK policies, procedures and guidelines.
• Adheres to CMS and state guidelines and social work/chaplain standards of practice.
• Adheres to NHPCO Ethical Practices and, as per discipline, the National Association of Social Workers Code of Ethics or National Board for Certified Pastoral Counselors’ Code of Ethics.

Requirements - what you need

• Master of Social Work from accredited university or MDiv, Master of Pastoral Care, Master of Theological Studies from accredited university
• For Social Work candidates, LCSW required or within first 2 years of hire.
• Minimum one-year experience in health-related field.
• Hospice experience preferred.
• Pediatric experience preferred.
• Able to communicate clearly with patients, families, visitors, IDG team, physicians, facility staff, leadership, and others.
• Able to teach patients and families in accordance with the plan of care.
• Able to independently seek out resources and to work collaboratively with a team.
• Able to use computer and learn new software programs
• Must have and maintain a valid North Carolina Driver’s License, maintain automobile insurance coverage, and have access to reliable transportation.

• Must be able to travel to, enter and function in the homes/facility of any patient/family in the service area to assess and provide care to all patients.
• May be required to lift and/or carry items up to 50 pounds.
• Must have sensory abilities to complete physical assessment, communicate with patient/family care providers and physician, and to complete the reporting and follow-up documentation responsibilities of the job.

• Work hours and days including weekend and holiday commitments as outlined in Employee Information
• Knowledgeable about reimbursement sources, Medicare regulations, licensing laws, and accreditation standards.