Hospice Care Transitions Coordinator - RN Liaison

The Hospice Care Transitions Coordinator is a clinical liaison position between health care providers to ensure continuity of care for patients transitioning from a facility to hospice environment. The position has the following general responsibilities: (1) after receipt of a referral for hospice services the CTC will assess the medical needs of the potential hospice patient and ensure that all necessary orders, documentation and collaboration between the referral source, the physician and the care center have been completed prior to the patients acceptance into hospice services (2) discussing the hospice benefit with patient/caregiver and having conversations with them regarding terminal illness, death and dying, palliative care where applicable and comfort care and symptom management (3) developing the referral relationships of the care center within the community, in accordance with Amedisys policies and procedures.

1) After a patient has selected Amedisys as his or her health care provider, the Care Transitions Coordinator visits the patient/caregiver onsite to review the physician order, assess the patient's clinical needs and gather clinical information. When applicable the Hospice Care Transitions Coordinator may also present consents for the family/POA to sign and help complete DNR paperwork that the care center will need on the patient. The Care Transitions Coordinator uses a Point of Service computer application to collect referred patient data onsite and transmit it to the care center. The Care Transitions Coordinator also facilitates patient involvement in his or her own care by providing education and obtaining the necessary information required for successful transition to home.

2) The Care Transitions Coordinator is also responsible for ensuring the patient has a physician and obtains an order from that physician to oversee the home health or hospice plan of care.

3) The Care Transitions Coordinator is also responsible for establishing, growing and maintaining relationships with facility-based referral sources, in accordance with Company policies and procedures, by both communicating with existing referral sources and identifying new opportunities.

1. RN strongly preferred. LPN, PT, OT are considered in some cases (with a current, active, unencumbered license in the state of service);

2. 1 years previous experience assisting patients through the continuum of care and the transition from hospital to home care or hospice.

3. Current CPR certification

4. Competent organizational skills;

5. Ability to handle stressful situations/deadlines;

6. Excellent oral/written communication and interpersonal skills;

7. Must demonstrate the ability to communicate effectively with all members of the health care team;

8. Demonstrates desire to work in a marketing role; and

9. Ability to forecasts needs and set priorities.

10. Proficient in computer-based skills. Must have working knowledge and practical application experience with general office computer systems (i.e. Microsoft Excel), internet, email, desktop navigation.

Amedisys is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, pregnancy, marital status, national origin, citizenship status, disability, military status, sexual orientation, genetic predisposition or carrier status or any other legally protected characteristic.

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