Patient Transition Liaison

Pathways Healthcare is a leading, physician- and nurse practitioner-led home health and hospice organization, committed to redefining recovery through comprehensive, patient-centered care. Our innovative Medical Rehabilitation Program offers a meaningful alternative to institutional rehab, helping people heal at home, with dignity and purpose.

As one of the first home health agencies to adopt AI-assisted documentation, we're investing in tools that give our clinicians time back – saving 5 to 10 hours per week! We have made a deliberate decision not to raise our productivity expectations, so the patients and clinicians win in the end. Technology handles the paperwork and your clinical judgment stays at the center of every note!

The Patient Transition Liaison plays a key role in fulfilling Pathways’ mission by supporting our patients in their continuum of care from home health to palliative care and/or hospice care. The Patient Transition Liaison assists in evaluating patient needs, collaborating closely with internal clinical teams, and ensuring seamless, timely, and safe transitions between Pathways divisions. They collect and verify required patient information, communicate updates to interdisciplinary teams, and maintain strong relationships with internal departments and external referral partners.
 

• Main Office location: Worcester, MA
• Job Type: Full Time
• Schedule: Monday - Friday
  Role is primarily remote; in-office meetings as required.
  
  

• →Build and maintain relationships with home health, palliative, and hospice teams
• →Communicate regularly with case managers and physicians about patient status
• →Meet with patients and families to assess needs and readiness for hospice care
• →Coordinate with physicians, clinical teams, facilities, and caregivers to ensure smooth and timely transitions
• →Update internal teams on any changes to admission schedules
• →Support the opening and growth of new centers
• →Participate in in-services, meetings, and daily operational briefings
• →Share accurate patient information so care teams can provide effective care
• →Maintain patient confidentiality at all times
• →Report incidents and safety concerns promptly
• →Follow infection control guidelines and safety procedures
• →Attend required trainings and complete monthly education modules
• →Listen to and respond appropriately to patient and family feedback
• →Verify insurance coverage and obtain required authorizations
• →Meet a quota of 12 hospice admissions per month
  
  

• Bachelor’s degree preferred
• At least two years of healthcare and/or marketing experience preferred
• Strong verbal and written communication skills
• Excellent interpersonal and organizational skills
• Ability to work independently with minimal supervision
• Comfortable learning and using new technology
• Valid driver’s license and reliable transportation