Position Summary:

The Palliative Care Transitions Specialist manages patients through the palliative continuum - from referral and eligibility screening, through active palliative care coordination, to timely transitions into hospice or other appropriate levels of care. This is a transitions-focused role: the Specialist identifies palliative-appropriate patients early, keeps care moving across providers, patients, families, and facilities, and ensures goals-of-care and hospice conversations happen at the right time. The ideal candidate is clinically grounded, compassionate, highly organized, and comfortable working across multiple systems and markets. 

Key Responsibilities: 

Referral & Eligibility Screening 

• Review incoming referrals for palliative appropriateness - diagnosis, prognosis, and treatment status - and classify as appropriate, borderline, or insufficient information; escalate unclear PCP notes for provider review. 

• Confirm patient eligibility and coverage windows before care is initiated. 

• Ensure referrals are correctly tagged as palliative in Zoho so intake prioritizes them, and expedite urgent referrals through the appropriate market channels and scheduling contacts. 

• Complete chart reviews using the standard review template, consistently across reviews. 

Care Transitions 

• Own the transition from palliative care to hospice: identify patients approaching hospice eligibility, coordinate goals-of-care and hospice discussions, and coordinate handoffs between palliative providers, hospice, and facilities. 

• Coordinate urgent palliative-care and telehealth visits for goals-of-care and hospice conversations. 

• Track patients across transition points so no one falls through the gaps between palliative, hospice, and primary care. 

Care Coordination 

• Complete individualized care plans and perform care management using Ennoble Care's EMR (OA/Order & MatrixCare and related systems). 

• Serve as a point of contact between providers, patients/families, SNFs, and partner facilities to keep care plans complete, accurate, and moving. 

• Communicate patient emergent needs and life-threatening episodes to the primary care clinician or designee. 

Documentation & Reporting 

• Track and document Chronic Care Management (CCM) minutes accurately; support monthly CCM summaries and flag reporting discrepancies. 

• Document all patient communications (verbal or written) accurately and in a timely manner, adhering to documentation protocols and best practices. 

• Support review reports, CREST reports, and end-of-month reviews as directed. 

Communication & Team Support 

• Keep the Director of Palliative Care informed of issues pertinent to the care plan and transition process and any known or perceived risks. 

• Contribute as a positive, constructive member of the palliative team and support cross-market coordination. 

Qualifications 

• No specific professional license is required. Candidates may hold an LPN, RN, or Social Worker (BSW or greater) background. 

• Direct clinical experience or hands-on patient care in hospice or palliative care is required. 

• Working knowledge of healthcare terminology, palliative and hospice eligibility criteria, and goals-of-care concepts. 

• Comfortable on the phone for large portions of the day. 

• Highly organized; able to multitask across patients, markets, and workstreams while remaining accurate and efficient. 

• Proficient with computers, Outlook, and Microsoft Office; able to learn EMR (OA/MatrixCare), Zoho CRM, secure email, and telephone systems. 

• Thrives in a fast-paced, changing environment; positive, adaptable team player willing to learn continuously. 

• Must pass a background check.