Life Transitions Benefit Counselor

Millennium Physician Group•Port Charlotte, FL

1d•Hybrid

About The Position

We are excited to announce an opening for a Life Transitions Benefit Counselor! The Life Transitions Benefit Counselor is a licensed clinical professional responsible for guiding patients and families through end-of-life care decisions within a value-based care model. This role serves as a critical bridge between patients, caregivers, internal care teams, and hospice partners to ensure timely, appropriate, and compassionate transitions to hospice care. Leveraging clinical expertise and strong communication skills, this individual manages the full hospice referral lifecycle while supporting informed decision-making and aligning care with patient goals and preferences.

Requirements

Active, unrestricted licensure in one of the following: Registered Nurse (RN) Licensed Clinical Social Worker (LCSW) Social Worker (SW) or equivalent clinical licensure
Experience with home visits required
3+ years of experience in hospice, palliative care, care management, or complex care coordination
Strong understanding of hospice eligibility criteria, end-of-life care planning, and goals-of-care discussions
Demonstrated ability to navigate sensitive conversations with empathy, clarity, and professionalism
Experience working within a value-based care or managed care environment preferred

Responsibilities

Serve as the primary day-to-day clinical point of contact for hospice partners, ensuring strong collaboration and seamless care coordination.
Coordinating Monthly Joint operating meetings with local hospices in collaboration with MPG clinical and administrative teams.
Receive, triage, and manage hospice referrals from Primary Care Providers (PCPs) and Care Management teams, prioritizing based on clinical need and urgency.
Assess and validate hospice eligibility in alignment with hospice partner criteria, using clinical judgment and available patient data.
Lead initial and ongoing goals-of-care conversations with patients, families, and caregivers, providing education on prognosis, hospice services, and end-of-life options in a compassionate, patient-centered manner.
Own and drive the end-to-end hospice referral process—from initial patient engagement through hospice acceptance—ensuring timely progression and clear communication across all stakeholders.
Maintain proactive engagement with eligible but not yet ready patients, using clinical insight and relationship-building to revisit conversations as conditions evolve.
Work closely with Clinical Operations and Healthcare Economics to actively track and quantify opportunity. This includes building, maintaining, and routinely reviewing a dashboard that clearly outlines performance, gaps, and targets.
Actively use information to drive alignment, and ensure action is being taken at the care team level.
Connect patients and families who are not eligible for hospice to other Millenium and community resources
Navigate and operate effectively within the Millennium Physician Group ecosystem, understanding patient flow, referral pathways, and internal coordination across clinical teams.