Palliative Care Transitions Specialist

Responsibilities

• Review incoming referrals for palliative appropriateness and classify them
• Confirm patient eligibility and coverage windows
• Manage transitions from palliative care to hospice, including coordinating goals-of-care discussions
• Coordinate urgent palliative-care and telehealth visits
• Complete individualized care plans using EMR systems like MatrixCare
• Serve as a point of contact between providers, patients, families, and facilities
• Document Chronic Care Management (CCM) minutes and patient communications accurately
• Keep the Director of Palliative Care informed of risks and care plan issues

Requirements

• Direct clinical experience or hands-on patient care in hospice or palliative care
• Working knowledge of healthcare terminology and palliative/hospice eligibility criteria
• Proficiency with Microsoft Office, Outlook, and EMR systems
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