RN Care Manager, Supportive/Palliative Care

 

What You'll Do 

The Supportive/Palliative Care Registered Nurse (RN) delivers high-quality, person-centered clinical support to patients living with serious and progressive illness. The RN helps patients and families clarify goals, manage symptoms, navigate complex care decisions, and access the right services at the right time. This role works across clinical and operational partners to strengthen the supportive and palliative care model, improve patient and caregiver experience, and support care that is aligned with each patient’s goals and needs. 

The Day to Day 

• Conduct comprehensive clinical assessments focused on symptom burden, functional status, psychosocial needs, caregiver capacity, health literacy, and goals of care. 
• Establish trusting relationships with patients and caregivers through compassionate, culturally responsive communication. 
• Provide education and coaching related to disease progression, symptom management, medication use, advance care planning, and available supportive services. 
• Identify changes in condition, unmet needs, and clinical risk; escalate concerns through appropriate clinical pathways. 
• Facilitate timely goals-of-care conversations in collaboration with the treating clinician and broader care team. 
• Support advance care planning, including documentation and communication of patient preferences when appropriate. 
• Coordinate care across primary care, nephrology, specialty care, hospice, home-based services, behavioral health, social services, and community resources. 
• Help patients and caregivers understand treatment options, expected outcomes, and transitions in care. 
• Participate in interdisciplinary case reviews and contribute nursing expertise to individualized care plans. 
• Work collaboratively with supportive care RNs and other members of the care team to coordinate patient support, share clinical insights, and promote continuity of care. 
• Track follow-up needs and close communication loops with patients, caregivers, and internal and external partners. 
• Document assessments, interventions, education, care coordination, and outcomes accurately and in a timely manner. 
• Identify recurring barriers or gaps in care and contribute to workflow, education, and program improvement initiatives. 
• Model the principles of supportive and palliative care in every patient and team interaction. 
• Review referrals, registries, and clinical information to identify patients who may benefit from supportive or palliative care. 
• Engage patients and caregivers using clear, non-stigmatizing language that distinguishes supportive and palliative care from end-of-life care. 
• Assess readiness, preferences, and barriers to participation. 
• Complete structured nursing assessments and synthesize clinical, functional, psychosocial, and caregiver information. 
• Collaborate with the care team to develop practical, goal-concordant plans. 
• Prioritize urgent symptoms, safety concerns, caregiver strain, and transitions in care. 
• Provide proactive follow-up based on patient need and care-plan goals. 
• Reinforce symptom-management strategies and connect patients to appropriate clinical and community resources. 
• Coordinate transitions between settings and help reduce avoidable fragmentation in care. 
• Reassess goals and needs as the patient’s condition or circumstances change. 
• Bring a nursing perspective to case conferences, program design, and operational problem-solving. 
• Share insights about patient and caregiver needs, access barriers, and opportunities to improve care delivery. 
• Contribute to onboarding, peer learning, and development of supportive/palliative care workflows and educational materials. 

Qualifications