Hospice Care Transition Coordinator

Company

Compassus

Position Summary

The Hospice Care Transition Coordinator is responsible for modeling the Compassus values of Compassion, Integrity, Excellence, Teamwork, and Innovation and for promoting the Compassus philosophy, using the 6 Pillars of Success as the foundation. S/he is responsible for upholding the Code of Ethical Conduct and for promoting positive working relationships within the company, among all departments, and all external stakeholders. The Hospice Care Transition Coordinator serves as a trusted resource for the physician and communicates with referral sources. S/he conducts skilled conversations with physicians, patients, families, and healthcare providers. S/he maintains an understanding of hospital and post-acute healthcare systems. The Hospice Care Transition Coordinator navigates getting patients into the right care at the right time.

Position Specific Responsibilities

• Regularly meets with physicians in the hospital to discuss specific patients:
• Documents interaction in salesforce.
• Gives guidance and provides understanding of post-acute service support.
• Ensures continuity of care as a priority.
• Communicates data sets to clinicians (e.g., Care Delivery Scorecard, predictive analytics, prognostic scores).
• Collaborates with existing palliative care in hospital:
• Supports transition to hospice services.
• Educates on post-acute benefits and Medicare/ payer coverage.
• Capacity to conduct and complete Goals of Care discussions/Advance Care Planning/Resuscitative Preferences:
• Acquires knowledge to complete POLST/MOLST/DNR, as needed.
• Understands disease trajectories; explains risk/benefits of treatments.
• Communication:
• Understands steps to explaining disease trajectory (recovery, chronic or terminal trajectories) and knows steps to offering a difficult prognosis.
• Identifies barriers that patients/families have towards understanding disease trajectories and prognosis.
• Identifies steps to having a successful family meeting.
• Maintains documentation of patient/family goals of care:
• Know how to complete a GOC visit using Compassus tools.
• Aligns recommendations between patient/family and Primary care team:
• Identifies patient preferences/needs.
• Identify patient’s post-acute care needs.
• Confirm the level of care most appropriate for the patient - right care, right time.
• Facilitate 'transition to home' planning including assessing post-discharge needs and developing and implementing transition to home plan.
• Sets patient-centered treatment goals and facilitating transitions.
• Coordinates patient care by obtaining H&P, physician orders, hospital records and face to face documentation in a timely manner.
• Identifies primary care physician to follow the plan of care.
• Ensures excellent customer service to maintain and grow the business in the identified key accounts.
• Meets or exceeds assigned quotas, thereby maintaining and constantly improving the Company's competitive position.
• Understands roles and responsibilities of the surrogate decision-maker especially around admission/POC.
• Maintains current list of admission coordinators for each healthcare service line.
• Performs other duties as assigned.
  

Education And/or Experience

• Associate or Bachelor's degree in Nursing required.
• Two (2) to three (3) years of nursing experience required
• Experience in healthcare marketing preferred.
• Hospital and/or long-term care clinical experience highly preferred.
  
  

Skills

• Mathematical Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percentage.
• Language Skills: Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from leaders, team members, investors, and external parties. Strong written and verbal communications.
• Other Skills and Abilities: Ability to understand, read, write, and speak English. Articulates and embraces hospice philosophy.
  
  

Certifications, Licenses, and Registrations

• Active and unencumbered Registered Nurse license in state(s) of employment required.
  
  

Physical Demands and Work Environment: The demands of this role necessitate a team member to effectively perform essential functions. Adaptations can be made to accommodate team members with disabilities. Regular standing, walking, and manual dexterity are fundamental, along with the ability to lift and move objects up to 50 pounds. Visual acuity requirements include close and distance vision, color and peripheral vision, depth perception, and the ability to adjust focus. In a healthcare setting, exposure to bodily fluids, infectious diseases, and conditions typical to the field is expected. Routine use of standard medical equipment and tools associated with clinical care is essential. This description provides a general overview and may vary by role and department, capturing the nuanced demands and conditions inherent to clinical positions in our organization.

At Compassus, including all Compassus affiliates, diversity, equity, and inclusion are fundamental to our Pillars of Success. We are committed to creating a fair work environment where our team members feel welcomed, highly valued, and respected. As an equal opportunity employer, all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.