Palliative Care Transitions Specialist

Referral & Eligibility Screening:

• Review incoming referrals for palliative appropriateness and classify as appropriate, borderline, or insufficient.
• Confirm patient eligibility and coverage windows before care initiation.
• Ensure referrals are correctly tagged in Zoho for intake prioritization.

Care Transitions:

• Own the transition from palliative to hospice by identifying eligible patients and coordinating goals-of-care discussions.
• Coordinate urgent visits for goals-of-care and hospice conversations.
• Track patients across transition points to prevent gaps in care.

Care Coordination:

• Complete individualized care plans using EMR systems (OA/MatrixCare).
• Serve as point of contact between providers, patients, families, and facilities.
• Communicate patient emergent needs to primary care clinician.

Documentation & Reporting:

• Accurately track Chronic Care Management (CCM) minutes and support monthly summaries.
• Document all patient communications adhering to protocols.
• Support review reports and end-of-month reviews.