Hospice Transitional Care RN - North Team

Job Title

Hospice Transitional Care RN (North Team)

The Hospice Transitional Care RN is responsible for coordinating and facilitating smooth transitions of care for hospice‑eligible patients across hospitals, facilities, physician offices, and community settings. This role serves as a clinical liaison between referral sources, patients, families, and the hospice interdisciplinary team to support timely hospice evaluations, admissions, and continuity of care.

Graduate from an accredited Diploma, Associate, or Baccalaureate School of Nursing.

Current state license as a registered nurse (RN) and/or in accordance with the Board of Nurse Examiners rules for the Nurse Licensure Compact. Current driver’s license. Valid and current CPR certification.

Minimum of two years’ experience as a registered nurse in hospice, palliative care, home health, acute care, or related healthcare setting. Hospice admissions or care coordination experience preferred.

Strong clinical assessment and critical thinking skills. Excellent communication and interpersonal skills. Ability to build professional relationships with referral sources, hospitals, facilities, physicians, patients, and families. Comfortable navigating hospital environments and collaborating with clinical teams. Knowledge of hospice eligibility criteria, Medicare regulations, and end‑of‑life care principles preferred. Ability to work independently while collaborating effectively within an interdisciplinary team. Compassionate, patient‑focused approach to care.

Must read, write, and comprehend English.

Reliable transportation and valid auto liability insurance.

Works in hospitals, patients’ homes, nursing facilities, physician offices, and community settings in various conditions; possible exposure to blood, bodily fluids, and infectious diseases; ability to travel locally; flexible schedule may be required; some exposure to unpleasant weather conditions.

• Review referrals, hospital records, and clinical documentation to identify hospice eligibility and appropriateness of care.
• Coordinate and facilitate smooth patient transitions from hospitals, facilities, physician offices, and community settings into hospice services.
• Conduct clinical evaluations and bedside assessments for potential hospice admissions.
• Provide hospice informational visits and education to patients, families, caregivers, referral sources, and community partners regarding hospice philosophy, services, eligibility criteria, and goals of care.
• Serve as a hospice educator and resource for patients, families, facilities, and referral partners.
• Collaborate closely with physicians, hospital case managers, social workers, discharge planners, facility staff, and interdisciplinary team members.
• Support discharge planning and care coordination to ensure safe and timely transitions to hospice services.
• Assist with obtaining necessary documentation, physician orders, consents, and clinical information required for hospice admission.
• Support timely coordination of admissions, including 24‑hour visits when needed, to promote continuity of care and positive patient outcomes.
• Monitor and communicate changes in patient condition or referral status to the Admissions Director and hospice team.
• Maintain accurate and timely documentation in the electronic medical record (EMR).
• Ensure compliance with Medicare, Medicaid, HIPAA, accreditation standards, and organizational policies.
• Participate in quality assessment and performance improvement (QAPI) initiatives.
• Promote Lighthouse Hospice Care’s mission, philosophy, and commitment to compassionate end‑of‑life care.
• Build and maintain positive professional relationships with hospitals, facilities, physicians, and community referral partners.
• Participate in hospice‑sponsored training, in‑service programs, and continuing education opportunities.
• Perform other duties as assigned.

Medical, Dental, Vision, and Life Insurance, Employee Assistance Program, Employee Referral Program, Paid Holidays, PTO Accrual, and 401(K).

$90,000/year – $100,000/year BOE

Prolonged standing and walking required, with ability to lift up to 50 lbs. and move patients. Requires working under stressful conditions to meet deadlines, patient needs, and referral coordination demands. Requires strong organizational skills, critical thinking, communication abilities, and the ability to make timely clinical decisions.