Palliative Care Transitions Specialist

Ennoble Care is a mobile primary care, palliative care, and hospice service provider serving patients across multiple states. Their clinicians provide in-home care for individuals with chronic conditions and limited mobility, offering programs like remote patient monitoring, behavioral health management, and chronic care management.

The Palliative Care Transitions Specialist manages patients through the palliative continuum, from referral and eligibility screening to timely transitions into hospice or other appropriate levels of care. This role focuses on identifying palliative-appropriate patients early, coordinating care across providers, patients, families, and facilities, and ensuring goals-of-care and hospice conversations occur 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 based on diagnosis, prognosis, and treatment status, classifying them 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 to prioritize them and expedite urgent referrals through appropriate market channels and scheduling contacts.
• Complete chart reviews using the standard review template, consistently across all reviews.

• Care Transitions

  • Own the transition from palliative care to hospice, including identifying patients approaching hospice eligibility, coordinating goals-of-care and hospice discussions, and managing 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 to ensure no 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.