The Continuous Care Coordinator (CCC) is a licensed practical nurse responsible for ensuring timely, compliant, and high-quality delivery of the Continuous Home Care (CHC) level of care. This role blends direct patient care, clinical coordination, and team oversight, ensuring that hospice patients in crisis receive symptom management aligned with Centers for Medicare & Medicaid Services (CMS) regulations and organizational standards.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Clinical Assessment & Coordination

Receive and respond promptly to referrals for Continuous Care (new and existing patients).
Collaborate with the RN Case Manager, hospice physician, and clinical leadership to evaluate and confirm the medical necessity and appropriateness of Continuous Care.
Ensure that all Continuous Care episodes meet regulatory requirements, including symptom crisis definitions and staffing ratios.

Scheduling & Staffing

Manage and schedule Continuous Care team members to provide appropriate coverage aligned with patient need, acuity, and CMS requirements.
Maintain 24/7 Continuous Care coverage while optimizing labor resources and minimizing avoidable overtime or inefficiencies.
Serve as the clinical point person for schedule adjustments, staffing gaps, call-offs, and urgent coverage needs.

Documentation & Compliance

Review and approve all Continuous Care clinical documentation for accuracy, completeness, and regulatory compliance.
Verify documentation supports eligibility for billing at the Continuous Care level of care.
Monitor the quality of notes, symptom assessment, interventions, and care plan updates.
Ensure completion and accuracy of EMR entries related to Continuous Care episodes, including level-of-care transitions.

Direct Patient Care

Provide direct Continuous Care patient care when necessary to support staffing shortages, emergent needs, or high census periods.
Deliver skilled nursing interventions, rapid symptom management, and crisis care under the hospice plan of care.

Leadership, Training & Performance Management

Interview, hire, and onboard new Continuous Care staff in alignment with staffing grid and organizational needs.
Provide ongoing training to Continuous Care teammates on hospice regulations, documentation standards, clinical competencies, and symptom management protocols.
Conduct initial and annual competencies, performance evaluations, and coaching conversations.
Promote a positive, supportive clinical team culture aligned with hospice values of compassion, dignity, and excellence.

Episode Management

Identify and coordinate the transition out of Continuous Care when the patient stabilizes or needs are resolved.
Ensure accurate documentation of level-of-care changes and timely updates in the EMR and billing systems.
Makes timely, sound clinical decisions in high-acuity situations.
Performs all other duties as assigned.

SUPERVISORY RESPONSIBILITIES

Provides oversight of the continuous care team by handling training, schedule changes, staffing gaps, and call-offs, ensuring appropriate coverage that meets patient needs and CMS requirements.

QUALIFICATIONS EDUCATION and/or EXPERIENCE

To perform this job successfully, an individual must be able to perform each primary function satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.
Valid LPN license (Florida or applicable state) with 2+ years of nursing experience, ideally in hospice, palliative, critical, or acute care.
Strong clinical and rapid-assessment skills, including symptom crisis management, pain, and respiratory distress management.
Knowledge of Medicare/CMS hospice regulations, especially Continuous Home Care, with solid documentation integrity.
Proficient with EMRs (MatrixCare preferred).
Excellent communication, multitasking, organization, and prioritization abilities.

Preferred: experience in hospice continuous/crisis care, leadership or team coordination, and scheduling or managing shift-based operations.