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Salary: USD 40,000 - 0 / annual
Ennoble Care is a mobile primary care, palliative care, and hospice service provider operating across New York, New Jersey, Maryland, DC, Virginia, Oklahoma, Kansas, Pennsylvania, Texas, Florida, and Georgia. The company brings clinicians to patients' homes to provide continuity of care for those with chronic conditions and limited mobility.
The Palliative Care Transitions Specialist manages patients through the palliative continuum—from referral and eligibility screening through active palliative care coordination to timely transitions into hospice or other appropriate levels of care. This is a transitions-focused role requiring clinical grounding, compassion, strong organizational skills, and comfort working across multiple systems and markets.
Key responsibilities include:
**Referral & Eligibility Screening:** Review incoming referrals for palliative appropriateness (diagnosis, prognosis, treatment status) and classify as appropriate, borderline, or requiring additional information. Escalate unclear provider notes for review. Confirm patient eligibility and coverage windows before care initiation. Ensure referrals are correctly tagged in Zoho CRM so intake prioritizes them, and expedite urgent referrals through appropriate market channels. Complete chart reviews using standardized templates consistently.
**Care Transitions:** Own the transition from palliative care to hospice by identifying patients approaching hospice eligibility, coordinating goals-of-care and hospice discussions, and managing handoffs between palliative providers, hospice, and facilities. Coordinate urgent palliative-care and telehealth visits for goals-of-care conversations. Track patients across transition points to ensure continuity between palliative, hospice, and primary care.
**Care Coordination:** Facilitate communication among patients, families, providers, and facilities. Document interactions and maintain accurate records in EMR and CRM systems. Respond to inquiries from patients, families, and providers regarding care status and transitions.
The ideal candidate is clinically grounded, compassionate, highly organized, and comfortable navigating complex healthcare systems across multiple markets.
**Requirements:**
- Clinical background or healthcare experience (nursing, social work, care coordination, or similar)
- Strong understanding of palliative care, hospice eligibility, and end-of-life care principles
- Excellent communication skills (verbal and written) with ability to engage sensitively with patients, families, and providers
- Proficiency with computers, Outlook, and Microsoft Office; ability to learn EMR (OA/MatrixCare), Zoho CRM, secure email, and telephone systems
- Ability to thrive in fast-paced, changing environments; positive, adaptable team player with continuous learning mindset
- Must pass background check
- Candidates must disclose any current or future need for employment-based immigration sponsorship before offer extension
