What You'll Do

Coordinate Referrals and Transitions of Care

• Serve as the primary point of contact for referral coordination across all Transitions LifeCare service lines


• Evaluate referrals and assess eligibility for hospice, palliative care, and other organizational services


• Facilitate seamless transitions from hospital to home, facility, or hospice inpatient care


• Collaborate with discharge planners, physicians, social workers, and care teams to coordinate appropriate care plans

Support Patients and Families

• Meet with patients and families to provide education and guidance regarding hospice, palliative care, and available support services


• Conduct informational visits within hospitals and community-based settings


• Facilitate goals-of-care conversations and support informed decision-making


• Provide emotional support during difficult transitions and end-of-life discussions

Serve as the Hospital Hospice Expert

• Round regularly within assigned hospitals


• Build strong partnerships with hospital leadership and clinical teams


• Educate healthcare professionals on hospice eligibility, levels of care, and Transitions LifeCare services


• Provide in-service training and educational presentations

Manage Hospice General Inpatient (GIP) Patients

• Complete General Inpatient hospice admissions within assigned hospitals


• Function as the hospice RN Case Manager for GIP patients


• Coordinate the hospice plan of care with hospital staff and interdisciplinary team members


• Monitor patient status and ensure appropriate symptom management and care delivery

Build Referral Relationships

• Partner with Provider Relations colleagues to strengthen referral relationships


• Assist with account management, customer service initiatives, and educational outreach


• Promote awareness of hospice and palliative care services within assigned hospitals


• Help grow referral volume through exceptional service and responsiveness

Who Thrives in This Role

• Strong clinical decision-makers


• Excellent communicators and educators


• Skilled relationship builders


• Comfortable working independently


• Passionate about patient advocacy


• Organized and highly adaptable


• Experienced in navigating complex healthcare systems


• Motivated by improving patient and family experiences

Required Qualifications

• Current Registered Nurse (RN) license in North Carolina


• Minimum two years of recent clinical nursing experience


• Strong assessment and critical thinking skills


• Excellent communication, organizational, and interpersonal skills


• Ability to independently prioritize workload and manage multiple responsibilities


• Strong computer proficiency


• Current CPR certification


• Valid North Carolina driver's license


• Reliable transportation and automobile insurance


• Ability to travel throughout the service area and function effectively in hospital environments


• Ability to lift and/or carry up to 50 pounds

Preferred Qualifications

• BSN


• Hospice experience


• Home health experience


• Palliative care experience


• Hospital case management experience


• Skilled nursing experience


• Knowledge of Medicare hospice regulations and levels of care


• Experience with hospital discharge planning


• Familiarity with EMR systems, Outlook, and Microsoft Office 365

Why This Role Matters

Join a Team with Purpose