Palliative Care Transitions Specialist

This is a fully remote position, open to applicants in Florida, +8 more states.

📋 Description

• Assess incoming referrals for palliative suitability based on diagnosis, prognosis, and treatment status; categorize referrals and escalate ambiguous notes for provider evaluation.

• Verify patient eligibility and coverage periods prior to the commencement of care.

• Label referrals as palliative in Zoho and prioritize urgent referrals through the correct market channels and scheduling contacts.

• Conduct chart reviews utilizing the standard review template.

• Oversee transitions from palliative care to hospice, which includes identifying patients nearing hospice eligibility, coordinating goals-of-care and hospice conversations, and facilitating handoffs.

• Organize urgent palliative-care and telehealth appointments.

• Monitor patients across transition points between palliative, hospice, and primary care.

• Develop individualized care plans and execute care management using Ennoble Care's EMR systems.

• Act as a liaison among providers, patients and families, SNFs, and partner facilities.

• Relay emergent patient needs and life-threatening situations to the primary care clinician or designated representative.

• Track and record Chronic Care Management minutes; assist with monthly CCM summaries and highlight reporting inconsistencies.

• Accurately and promptly document patient communications.

• Aid in review reports, CREST reports, and end-of-month evaluations.

• Keep the Director of Palliative Care updated on care plans, transition processes, and risk management issues.

• Contribute to cross-market coordination as a part of the palliative team.

⛳️ Requirements

• No specific professional license is mandatory; candidates may possess an LPN, RN, or Social Worker (BSW or higher) background.

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

• Familiarity with healthcare terminology, palliative and hospice eligibility criteria, and goals-of-care concepts is required.

• Comfortable using the phone for extended periods throughout the day.

• Highly organized; capable of multitasking across patients, markets, and workstreams while maintaining accuracy and efficiency.

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

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

• Must successfully complete a background check.

• Candidates should disclose any current or future requirement for employment-based immigration sponsorship, including OPT, STEM OPT, or visa sponsorship, prior to receiving a job offer.

🏝️ Benefits

• Medical, Dental, Vision, and additional benefits such as Life Insurance, Short Term and Long Term Disability, Flexible Spending Accounts for Medical and Dependent Care, Accident, Critical Illness, and Hospital Indemnity.

• Paid Time Off

• Paid Office Holidays

• Paid Sick Time

• 401(k) with up to 3% company match

• Referral Program

• Payactiv: pay-on-demand. Access earned money when and where you need it!