Job Location : Peterborough,NH, USA
Job Type Full-time Description 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 Care Transition Specialist 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. Requirements The successful Care Transition Specialist is a nurse, social worker or non-clinician with proven experience in increasing access to hospice, primarily focused from/in facilities including hospitals and knowledge of Medicare benefits. 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. HCS is unique in the wide range of community services that are offered to the community, including Foot Care Clinics, Healthy Starts maternal and child health services, Meals on Wheels and senior dining, City Express and Friendly Bus transportation. HCS is Medicare certified and licensed by the State of New Hampshire, and proud to be a Monadnock United Way agency.