PALLIATIVE AND HOSPICE CARE NAVIGATOR

Toledo Clinic; Toledo (OH); On-site; USD 85,000 - 110,000; Full time

Job summary

Toledo Clinic’s Hospice & Palliative Care Navigator leads proactive end-of-life reviews for high-risk patients, coordinating with PCPs, advocating for patients and families, and guiding goals‑of‑care discussions in a largely independent role.

You will maintain patient registries, prioritize panels by acuity, build physician relationships, and ensure documentation meets CMS requirements while advancing advance care planning and transitions of care.

Qualifications

• Active Ohio RN or LPN license; BSN preferred; 3+ years in clinical nursing, hospice or palliative care desirable.
• Strong knowledge of Medicare hospice and palliative care eligibility; proficient with EHRs.
• Ability to work independently while collaborating with physicians.

Responsibilities

• Maintain registry of high-risk patients to determine hospice or palliative care needs.
• Prioritize and manage patient panels based on acuity and urgency.
• Lead goals-of-care discussions with patients, families, and PCPs.
• Document assessments and recommendations in the medical record; ensure CMS compliance.
• Foster relationships with preferred hospice and palliative care agencies.

Skills

Goals-of-care conversations

EHR proficiency

Independent clinician

Relationship building with physicians

Clinical judgment

Education

Ohio RN or LPN license

BSN preferred

Tools

EHRs

Job description

The Hospice & Palliative Care Navigator is the clinical engine for the proactive end-of-life review program for identified value-based patients, maintaining real-time oversight of high-risk patients who may be hospice-eligible, palliative care-eligible, or appropriate for advance care planning. The Navigator partners closely with PCPs, supports goals-of-care conversations, advocates for patients and families, and owns relationships with preferred hospice and palliative care agencies. This is not a chart review or referral coordination role. The Navigator operates with a high degree of independence, exercises expert clinical judgment, and is accountable for program outcomes.

Patient Panel Management & Clinical Triage

• Maintain a living registry of high-risk patients using clinical lists, algorithms, diagnoses, utilization patterns, and chart review to determine hospice eligibility, palliative care needs, or advance care planning opportunities.
• Independently prioritize and manage the patient panel based on acuity, clinical trajectory, and urgency, while tracking and periodically re-evaluating patients who are not yet ready for enrollment.
• Build trusted relationships with PCPs and provide clinically substantive recommendations based on each physician’s communication style, needs, and patient population.
• Proactively follow up on recommendations, elevate unresolved cases when needed, and educate/coaching PCPs on hospice and palliative care eligibility, prognostic indicators, and goals-of-care best practices.

Goals-of-Care Conversation Support

• Serve as the market’s primary clinical resource for goals-of-care and hospice conversations by preparing physicians, providing clinical and communication context, participating in conversations, and independently leading appropriate discussions.
• Engage directly with patients and families in the clinic or field to provide compassionate education and support around hospice and palliative care, including eligibility, services, enrollment, and common misconceptions.

Advance Care Planning

• Identify and engage high-risk patients in advance care planning conversations focused on goals, values, and future care preferences, regardless of current hospice or palliative care eligibility.
• Partner with PCPs to ensure advance directives, POLST forms, and care preferences are completed, current, and accessible, recognizing ACP as foundational to appropriate future hospice and palliative care utilization.
• Maintain authoritative visibility into the market’s end-of-life patient pipeline, including eligibility, enrollment, progress, outstanding needs, and areas requiring intervention.
• Lead regular internal rounds with clinical and operational leadership using pipeline dashboards to identify bottlenecks, escalations, performance trends, and systemic workflow, scheduling, EHR, or physician-engagement barriers.

Preferred Agency Relationship Management

• Own day-to-day clinical and operational relationships with preferred hospice and palliative care agencies, including warm handoffs, joint clinical rounds, and Joint Operating Committee participation.
• Monitor agency capacity and quality, identify performance concerns, and collaborate with the ED and Medical Director to ensure timely, appropriate referrals and effective transitions of care.

Documentation & Evidence-Based Practice

• Accurately document patient assessments, physician recommendations, goals-of-care outcomes, enrollment status, and other required information in the medical record and designated tracking tools.
• Apply current Medicare hospice, palliative care, and CMS requirements while maintaining current knowledge of serious illness communication, advance care planning, and evidence-based palliative care practices.

Other Essential Duties May Include (but are not limited to )

• Comply with OSHA, HIPAA, and company policies while demonstrating strong communication, attention to detail, professionalism, composure in emotionally demanding situations, and accuracy in documentation and reporting.
• Maintain flexibility to meet patient and physician needs, participate in assigned projects, and take responsibility for ongoing professional development and clinical knowledge in end-of-life care.

Knowledge, Skills & Abilities Required:

Required Qualifications

• Active RN or LPN license required in the state of Ohio; in good standing. BSN preferred, or 10+ years of LPN experience in hospice. Minimum 3 years of clinical nursing experience, with hospice, palliative care, or serious illness experience strongly preferred.
• Demonstrated experience with goals-of-care and end-of-life conversations, strong knowledge of Medicare hospice and palliative care eligibility, proficiency with EHRs, and the ability to work independently while building effective relationships with physicians.

Preferred Qualifications

• Certified Hospice and Palliative Nurse (CHPN) credential and experience in value-based care, ACO, managed care, clinical navigation, care management, or program deployment.
• Familiarity with advance care planning frameworks such as POLST, Respecting Choices, and other state documents.