Hospice Care Transition Coordinator

Compassus • Austin, TX

1d • Onsite

About The Position

This is a weekend role - Friday, Saturday and Sunday coverage, 8AM - 5PM. This role will cover Ascension Dell Seton Medical Center and Ascension Seton Hays. Hospice and Home Health experience required. Registered Nurse required for this role. The Hospice and Home Health Care Transition Coordinator is responsible for modeling the Compassus values of Compassion, Integrity, Excellence, Teamwork, and Innovation and for promoting the Compassus philosophy, using the 6 Pillars of Success as the foundation. S/he is responsible for upholding the Code of Ethical Conduct and for promoting positive working relationships within the company, among all departments, and all external stakeholders. The Hospice and Home Health Care Transition Coordinator serves as a trusted resource for the physician and communicates with referral sources. S/he conducts skilled conversations with physicians, patients, families, and healthcare providers. S/he maintains an understanding of hospital and post-acute healthcare systems. The Hospice and Home Health Care Transition Coordinator navigates getting patients into the right care at the right time.

Requirements

• Associate or Bachelor's degree in Nursing required.
• Two (2) to three (3) years of nursing experience required
• Active and unencumbered Registered Nurse license in state(s) of employment required.
• Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percentage.
• Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from leaders, team members, investors, and external parties. Strong written and verbal communications.
• Ability to understand, read, write, and speak English.
• Articulates and embraces hospice philosophy.
• Regular standing, walking, and manual dexterity are fundamental, along with the ability to lift and move objects up to 50 pounds. Visual acuity requirements include close and distance vision, color and peripheral vision, depth perception, and the ability to adjust focus.
• In a healthcare setting, exposure to bodily fluids, infectious diseases, and conditions typical to the field is expected. Routine use of standard medical equipment and tools associated with clinical care is essential.

Nice To Haves

• Experience in healthcare marketing preferred.
• Hospital and/or long-term care clinical experience highly preferred.

Responsibilities

• Regularly meets with physicians in the hospital to discuss specific patients: Documents interaction in salesforce. Gives guidance and provides understanding of post-acute service support. Ensures continuity of care as a priority. Communicates data sets to clinicians (e.g., Care Delivery Scorecard, predictive analytics, prognostic scores).
• Collaborates with existing palliative care in hospital: Supports transition to hospice and home health services. Educates on post-acute benefits and Medicare/ payer coverage.
• Capacity to conduct and complete Goals of Care discussions/Advance Care Planning/Resuscitative Preferences: Acquires knowledge to complete POLST/MOLST/DNR, as needed. Understands disease trajectories; explains risk/benefits of treatments.
• Communication: Understands steps to explaining disease trajectory (recovery, chronic or terminal trajectories) and knows steps to offering a difficult prognosis. Identifies barriers that patients/families have towards understanding disease trajectories and prognosis. Identifies steps to having a successful family meeting. Maintains documentation of patient/family goals of care: Know how to complete a GOC visit using Compassus tools. Aligns recommendations between patient/family and Primary care team: Identifies patient preferences/needs.
• Identify patient’s post-acute care needs. Confirm the level of care most appropriate for the patient - right care, right time. Facilitate 'transition to home' planning including assessing post-discharge needs and developing and implementing transition to home plan. Sets patient-centered treatment goals and facilitating transitions.
• Coordinates patient care by obtaining H&P, physician orders, hospital records and face to face documentation in a timely manner. Identifies primary care physician to follow the plan of care.
• Ensures excellent customer service to maintain and grow the business in the identified key accounts. Meets or exceeds assigned quotas, thereby maintaining and constantly improving the Company's competitive position. Understands roles and responsibilities of the surrogate decision-maker especially around admission/POC. Maintains current list of admission coordinators for each healthcare service line.
• Performs other duties as assigned.

Benefits

• Meaningful Work: Make an impact every day by honoring the quality of life of our patients, supporting them and their families with compassion, and creating moments that truly matter.
• Career Development: Access leadership pathways, mentorship, and personalized professional development.
• Innovation Meets Compassion: Collaborate with a supportive team using the latest tools and technologies to deliver exceptional care.
• Enhanced Benefits: Enjoy competitive pay, flexible time off, tuition reimbursement, and wellness programs designed for your well-being.
• Recognition and Support: Be celebrated for your contributions through recognition programs that honor your dedication.
• A Culture of Belonging: Thrive in a culture where you can be your authentic self, valued for your unique contributions and supported in a community that embraces diversity and inclusion.

What This Job Offers

• Career Level: Mid Level
• Education Level: Associate degree