Care Transitions Specialist

Care Transitions Specialist 

The Care Transitions Specialist is responsible for maintaining collaborative relationships between HCS and all facility referral sources with the primary focus on hospice. Knowledge of Home Health and Palliative Services a plus. Educational informational presentations to the community, referral sources, patients, and families in various settings (hospitals, long-term care facilities, and/or community) are part of this role. The successful Care Transition Specialist is a nurse, RN or LPN that works closely with referral sources to streamline processes to ensure thorough and timely referrals and admissions. Presentation skills required to speak with MD’s, APRNs and other staff in hospitals, skilled nursing facilities and assisted living facilities. 
 
The Care Transition Specialist will also provide topical educational presentations for referral sources and in the community; meet with the Palliative care team as needed regarding patients that would benefit from hospice services; meet with patient/family to present hospice benefits and obtain consents; through understanding of hospice criteria; reimbursement for Medicare and Medicaid. 

Collaboration with Clinical Team and Care Coordination meetings in facilities is expected. 

 
Experience and education guidelines:
• Graduate of a National League for Nursing approved program, a Bachelor of Science degree in  
    Nursing preferred;
• A minimum of three (3) years’ experience in hospice, Long Term Care, or the equivalent. 

• Clinical nurse liaison experience preferred; or 
• A combination of education and experience that is determined to be equivalent to the above listed

Education and experience requirements;
• Possession of a current State of New Hampshire license to practice as a Registered Professional 
    Nurse or Licensed Practical Nurse  - if a nurse 
• Valid driver’s license with access to an automobile during working hours that meets the State of 
    New Hampshire’s registration regulations and auto liability insurance; and
• Must be able and willing to learn to utilize a portable electronic field device as well as manage
    electronic patient health information (ePHI) remote access in accordance with HCS' policies and 
    procedures.

 Home Healthcare, Hospice and Community Services (HCS) is a non-profit organization providing comprehensive services in southwestern New Hampshire. HCS’s clinical services include visiting nurses, physical and occupational therapies, social work, and home health aides. Hospice at HCS offers end of life care, grief support and Pet Peace of Mind for patients and family members wherever they call home, including in assisted living and nursing homes. Hospice at HCS rates above state and national averages in many important quality measures and maintains a 100% overall satisfaction rating (from data compiled by the Centers for Medicare and Medicaid.)  HCS is unique in the wide range of community services that are offered to the community, including Healthy Starts maternal and child health services, Meals on Wheels and senior dining, City Express and Friendly Bus transportation, Age in Motion exercise for older adults and Nurse Is In blood pressure and foot care clinics. HCS is Medicare certified and licensed by the State of New Hampshire, and proud to be a Monadnock United Way agency.