Hospice Care Transitions Coordinator

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The Hospice Care Transitions Coordinator plays a vital role in facilitating safe and effective transitions across the continuum of care. This nurse-led position focuses on discharge planning during hospital stays, emergency department visits, and transitions to and from skilled nursing facilities, long-term acute care centers, and rehabilitation settings. The role integrates clinical expertise, regulatory compliance, compassionate care, and strategic outreach to improve patient outcomes and promote hospice services.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Associate Degree in Nursing AND Five (5) years of hospice or palliative clinical experience.

OR

2. Bachelor’s Degree in Nursing AND Three (3) years of hospice or palliative clinical experience.

3. Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).

4. Basic Life Support certification within 30 days of hire date.

PREFERRED QUALIFICATIONS:

EXPERIENCE:

1. Experience in medical management for Medicare/Medicaid populations.

2. Experience in care coordination or liaison roles.

3. Experience in hospice care.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Collaborates with physicians, nurses, social workers, interdisciplinary teams, and external agencies to ensure timely, appropriate, and patient-centered transitions.

2. Works directly with palliative care teams and physicians to support patients with complex or advanced illnesses during transitions of care.

3. Delivers empathetic, person-centered care to patients nearing the end of life and leads collaborative goals of care discussions with the interdisciplinary team.

4. Apply clinical judgment and Medicare appropriateness criteria to discharge planning and resource utilization, ensuring compliance with regulatory guidelines.

5. Assesses patients for hospice eligibility, including all levels of hospice care.

6. Completes required hospice consents, admissions documentation, and clinical rationale for level of care.

7. Performs RN evaluations and assessments for hospice admission, hospice starts of care, patient/family education, and routine RN visits.

8. Reassesses GIP patients for continued appropriateness, documenting findings and rationale.

9. Documents clinical rationale supporting hospice and GIP levels of care in accordance with Medicare regulations.

10. Collaborates with care management, palliative care, and interdisciplinary teams to expedite hospice transitions and maintain hospital throughput and bed availability.

11. Serves as a primary point of contact for patients, families, and staff regarding hospice services, care plans, and discharge processes.

12. Attends Interdisciplinary Group (IDG) meetings with the Associate Medical Director to review plans of care and support collaborative decision-making.

13. Conducts death visits and provides family support following patient death.

14. Maintains accurate logs and reports related to hospice transitions, service lines, consult-to-admission timeliness, and quality performance improvement metrics.

15. Delivers detailed and compliant documentation in the EMR.

16. Develops structured education programs for hospital and community partners to promote awareness and collaboration in hospice care.

17. Participates in community hospice intake efforts to support informed, compassionate patient enrollment.

18. Engages in the hospice on-call rotation for after-hours care support and continuity.

19. Develops and implements strategies for market growth and program outreach.

20. Builds and maintains strategic relationships with hospitals, long-term care facilities, and physician practices.

21. Tracks and analyzes referral and performance data to inform business development.

22. Utilizes motivational interviewing techniques to encourage patient engagement and shared decision-making.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

SKILLS AND ABILITIES:

1. Outstanding communication and interpersonal skills.

2. Expertise in motivational interviewing and patient advocacy.

3. Strong knowledge of state/federal laws, hospice Conditions of Participation and discharge planning regulations.

4. High level critical thinking, problem solving and organizational abilities.

5. Precision in documentation and EMR utilization.

6. Proficiency in Microsoft Office Suite.

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

SHC WVUHS Home Care

Cost Center:

500 SHC Administration

Address:

1 Medical Center DriveMorgantownWest Virginia

Equal Opportunity Employer

West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.