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Transitional Care Navigator
Addus HomeCare. Expand the reach and impact of clinical hospice services by identifying and securing upstream referral sources and education and awareness opportunities .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in hospice clinical consultation, patient assessment, and relationship building with healthcare providers to enhance patient outcomes and facilitate appropriate hospice care. Proficient in clinical documentation review and education planning to support effective care transitions.
Highest-signal resume keywords
Hospice Clinical ConsultationPatient AssessmentClinical Documentation ReviewRelationship BuildingQuality Assessment Procedures
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Patient ProfilesClinical-Admission AssessmentsEMR ReviewHCHB ReviewHospice PoliciesPatient Eligibility EducationMedical-Record ReviewConsultation EducationCare Team WorkflowsTrend Identification
Soft Skills
Tactful CommunicationIndependent Decision-MakingCollaborationTeam-Focused EnvironmentRelationship Management
Certifications & Qualifications
Registered Nurse License
Industry Keywords
Hospice ServicesReferral SourcesPatient OutcomesEnd-of-Life SatisfactionHealthcare ProvidersCare CoordinationCommunity EngagementQuality AssurancePatient CareHealthcare Education
About the role
Key responsibilities & impact- Expand the reach and impact of clinical hospice services by identifying and securing upstream referral sources and education and awareness opportunities
- Build relationships and drive appropriate and dignified hospice care for patients across physicians, providers, and hospitals
- Build upstream-referral relationships and transition hospice referrals from physicians and other referral sources
- Serve as a hospice clinical consultant and educator, extending hospital and physician care teams
- Review hospital clinical documentation, EMR, and HCHB
- Engage patients and providers to build clinical patient profiles and clinical-admission assessments
- Identify decline patterns, including frequent hospitalizations and functional deterioration
- Consult with hospital care teams by sharing clinical profiles and educating on hospice appropriateness
- Identify attending and consulting providers associated with referred patients
- Provide patient assessment, eligibility, and discharge education and awareness
- Collaborate with field sales representatives to schedule and conduct consultative meetings with external care teams
- Initiate and maintain care team workflows for patient information, clinical assessment and documentation, consultation, education planning and delivery, and meetings
- Identify trends, needs, and partnership opportunities for earlier hospice engagement
- Foster relationships with external care teams to improve patient outcomes and end-of-life satisfaction
- Communicate with hospital leadership and care coordination teams
- Organize, track, and prioritize high-value patient comprehensive reviews
- Meet productivity requirements, including timely medical-record review and hospital/provider consultation and education
- Promote a collaborative, team-focused environment
- Uphold hospice policies, privacy practices, and ethical guidelines
- Represent the organization in hospitals, community, and partner interactions
- Collaborate with internal hospice departments and leadership teams
- Perform other duties as assigned
Requirements
What you’ll need- Bachelor’s degree in marketing, business administration, or other related fields is preferred
- An acceptable combination of experience and/or training may be considered instead of formal education
- Licensed as a registered nurse in the state of practice, preferred
- Minimum of two years relevant experience
- Ability to make independent decisions when circumstances warrant
- Ability to deal tactfully with patients, family members, visitors, agency personnel, and public
- Knowledge of quality assessment and assurance procedures
- Valid driver’s license and proof of insurance is required
Benefits
Comp & perks- Competitive salaries
- 401K retirement plan with a generous company match
- Comprehensive benefits (medical, dental, vision, life/AD&D, disability), effective on the first of the month
- Generous time off accruals
- Paid holidays
- Mileage reimbursement
- Tuition Reimbursement
- Employee Referral Program
- Merit Increases
- Employee Discount Programs
- Work/life balance