Palliative Care Transitions Specialist

🔥 12 minutes ago

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Ennoble Care

WebsiteLinkedInAll Job Openings

201 - 500 employees

Ennoble Care, where our mission is "To Care Is An Honor," is a community-based primary, palliative, and hospice care service providing care to patients and families. We have clinicians throughout New York, New Jersey, Maryland, DC, Virginia, and Georgia, who licensed and committed to providing you with exceptional care.

📋 Description

• The Palliative Care Transitions Specialist manages patients through the palliative continuum - from referral and eligibility screening to active palliative care coordination, to timely transitions into hospice or other appropriate levels of care. • 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. • 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. • 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. • 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. • 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.

🎯 Requirements

• 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.

🏖️ Benefits

• Medical, Dental, Vision and supplementary 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. Cash out earned money when and where you need it!