Palliative Care Transitions Navigator

ennoblecare; United States; Remote; USD 40,000 - 60,000; Full time

Benefits offered by this job

Medical insurance

Paid time off

Paid holidays

401k with company match

PayActiv access

Job summary

Ennoble Care is seeking a Palliative Care Transitions Specialist to manage patients through the palliative continuum—from referral and eligibility screening to transitions into hospice or other appropriate levels of care. This transitions-focused role requires clinical grounding, compassion, organization, and comfort working across multiple systems and markets.

The ideal candidate is clinically grounded, compassionate, highly organized, and comfortable working across multiple systems and markets.

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.

Responsibilities

• Referral & Eligibility Screening: Review incoming referrals for palliative appropriateness - diagnosis, prognosis, and treatment status - and classify as appropriate , borderline, or insufficient information; accelerate unclear PCP notes for provider review.
• Care Transitions: 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.
• Care Coordination: Complete individualized care plans and perform care management using Ennoble Care's EMR (OA/MatrixCare and related systems).
• Documentation & Reporting: Track and document Chronic Care Management (CCM) minutes accurately; support monthly CCM summaries and flag reporting discrepancies.
• 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.

Job description

Ennoble Care is seeking a Palliative Care Transitions Specialist to manage patients through the palliative continuum—from referral and eligibility screening to transitions into hospice or other appropriate levels of care. This transitions-focused role requires clinical grounding, compassion, organization, and comfort working across multiple systems and markets.

The ideal candidate is clinically grounded, compassionate, highly organized, and comfortable working across multiple systems and markets.