Care Navigator

• Expand the reach and impact of clinical hospice services by identifying and securing upstream referral sources and education opportunities
• Build relationships and drive appropriate 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 for hospital and physician care teams
• Review hospital clinical documentation, EMR, and HCHB records
• Engage patients and providers to build clinical patient profiles and admission assessments
• Identify decline patterns, including frequent hospitalizations and functional deterioration
• Educate care teams on hospice appropriateness
• Identify attending and consulting providers associated with referred patients
• Provide patient assessment, eligibility, discharge education, and awareness
• Collaborate with field sales representatives on consultative meetings with external care teams
• Initiate and maintain care team workflows for patient information, clinical assessment, documentation, consultation, education planning and delivery, and internal/external meetings
• Identify trends, needs, and partnership opportunities for earlier hospice engagement
• Foster trusted 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 comprehensive patient reviews
• Meet productivity requirements for medical-record review and hospital/provider consultation and education
• Collaborate cross-functionally with internal hospice departments and leadership teams
• Uphold hospice policies, privacy practices, and ethical guidelines
• Represent the organization professionally in hospitals, communities, and partner interactions
• Perform other duties as assigned

Transitional Care Navigator, RN

• Expand the reach and impact of clinical hospice services by identifying and securing new 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 hospice clinical consultant and educator, acting as an extension of hospital and physician care teams
• Review hospital clinical documentation, EMR, and HCHB
• Engage with patients and providers to build clinical patient profiles and clinical admission assessments
• Identify decline patterns such as 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 to provide assessment, eligibility, and discharge education
• Collaborate with field sales representatives on consultative meetings with external care teams
• Initiate and maintain workflows for patient information, clinical assessment, documentation, consultation, education, 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 comprehensive patient reviews
• Meet productivity requirements, including timely medical-record review and hospital/provider consultation and education
• Uphold hospice policies, privacy practices, and ethical guidelines
• Represent the organization professionally in hospitals, the community, and partner interactions
• Collaborate with internal hospice departments and leadership teams
• Perform other duties as assigned