Palliative Care Transitions Specialist (Remote)

Ennoble Care is a mobile primary care, palliative care, and hospice service provider with patients in New York, New Jersey, Maryland, DC, Virginia, Oklahoma, Kansas, Pennsylvania, Texas, Florida, and Georgia. Ennoble Care’s clinicians go to the home of the patient, providing continuum of care for those with chronic conditions and limited mobility. Ennoble Care offers a variety of programs including, remote patient monitoring, behavioral health management, and chronic care management, to ensure that our patients receive the highest quality of care by a team they know and trust. We seek individuals who are driven to make a difference and embody our motto, “To Care is an Honor.” Join Ennoble Care today!

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: the Specialist identifies palliative-appropriate patients early, keeps care moving across providers, patients, families, and facilities, and ensures goals-of-care and hospice conversations happen at the right time. The ideal candidate is clinically grounded, compassionate, highly organized, and comfortable working across multiple systems and markets. 

Referral & Eligibility Screening 

• →Review incoming referrals for palliative appropriateness - diagnosis, prognosis, and treatment status - and classify as appropriate, borderline, or insufficient information; escalate unclear PCP notes for provider review. 

• →Confirm patient eligibility and coverage windows before care is initiated. 

• →Ensure referrals are correctly tagged as palliative in Zoho so intake prioritizes them, and expedite urgent referrals through the appropriate market channels and scheduling contacts. 

• →Complete chart reviews using the standard review template, consistently across reviews. 

Care Transitions 

• →Own the transition from palliative care to hospice: identify patients approaching hospice eligibility, coordinate goals-of-care and hospice discussions, and coordinate handoffs between palliative providers, hospice, and facilities. 

• →Coordinate urgent palliative-care and telehealth visits for goals-of-care and hospice conversations. 

• →Track patients across transition points so no one falls through the gaps between palliative, hospice, and primary care. 

Care Coordination 

• →Complete individualized care plans and perform care management using Ennoble Care's EMR (OA/Order & MatrixCare and related systems). 

• →Serve as a point of contact between providers, patients/families, SNFs, and partner facilities to keep care plans complete, accurate, and moving. 

• →Communicate patient emergent needs and life-threatening episodes to the primary care clinician or designee. 

Documentation & Reporting 

• →Track and document Chronic Care Management (CCM) minutes accurately; support monthly CCM summaries and flag reporting discrepancies. 

• →Document all patient communications (verbal or written) accurately and in a timely manner, adhering to documentation protocols and best practices. 

• →Support review reports, CREST reports, and end-of-month reviews as directed. 

Communication & Team Support 

• →Keep the Director of Palliative Care informed of issues pertinent to the care plan and transition process and any known or perceived risks. 

• →Contribute as a positive, constructive member of the palliative team and support cross-market coordination. 

• No specific professional license is required. Candidates may hold an LPN, RN, or Social Worker (BSW or greater) background. 

• Direct clinical experience or hands-on patient care in hospice or palliative care is required. 

• Working knowledge of healthcare terminology, palliative and hospice eligibility criteria, and goals-of-care concepts. 

• Comfortable on the phone for large portions of the day. 

• Highly organized; able to multitask across patients, markets, and workstreams while remaining accurate and efficient. 

• Proficient with computers, Outlook, and Microsoft Office; able to learn EMR (OA/MatrixCare), Zoho CRM, secure email, and telephone systems. 

• Thrives in a fast-paced, changing environment; positive, adaptable team player willing to learn continuously. 

• Must pass a background check. 

Ennoble Care is an Equal Opportunity Employer, committed to hiring the best team possible, and does not discriminate against protected characteristics including but not limited to - race, age, sexual orientation, gender identity and expression, national origin, religion, disability, and veteran status.