Palliative And Hospice Care Navigator

The Hospice & Palliative Care Navigator is the clinical engine for the proactive end-of-life review program for identified value-based patients, maintaining real-time oversight of high-risk patients who may be hospice-eligible, palliative care-eligible, or appropriate for advance care planning. The Navigator partners closely with PCPs, supports goals-of-care conversations, advocates for patients and families, and owns relationships with preferred hospice and palliative care agencies.

This is not a chart review or referral coordination role. The Navigator operates with a high degree of independence, exercises expert clinical judgment, and is accountable for program outcomes.

• Maintain a living registry of high-risk patients using clinical lists, algorithms, diagnoses, utilization patterns, and chart review to determine hospice eligibility, palliative care needs, or advance care planning opportunities.
• Independently prioritize and manage the patient panel based on acuity, clinical trajectory, and urgency, while tracking and periodically re-evaluating patients who are not yet ready for enrollment.
• Build trusted relationships with PCPs and provide clinically substantive recommendations based on each physician’s communication style, needs, and patient population.
• Proactively follow up on recommendations, elevate unresolved cases when needed, and educate/coaching PCPs on hospice and palliative care eligibility, prognostic indicators, and goals-of-care best practices.

• Serve as the market’s primary clinical resource for goals-of-care and hospice conversations by preparing physicians, providing clinical and communication context, participating in conversations, and independently leading appropriate discussions.
• Engage directly with patients and families in the clinic or field to provide compassionate education and support around hospice and palliative care, including eligibility, services, enrollment, and common misconceptions.

• Identify and engage high-risk patients in advance care planning conversations focused on goals, values, and future care preferences, regardless of current hospice or palliative care eligibility.
• Partner with PCPs to ensure advance directives, POLST forms, and care preferences are completed, current, and accessible, recognizing ACP as foundational to appropriate future hospice and palliative care utilization.
• Maintain authoritative visibility into the market’s end-of-life patient pipeline, including eligibility, enrollment, progress, outstanding needs, and areas requiring intervention.
• Lead regular internal rounds with clinical and operational leadership using pipeline dashboards to identify bottlenecks, escalations, performance trends, and systemic workflow, scheduling, EHR, or physician-engagement barriers.

• Own day-to-day clinical and operational relationships with preferred hospice and palliative care agencies, including warm handoffs, joint clinical rounds, and Joint Operating Committee participation.
• Monitor agency capacity and quality, identify performance concerns, and collaborate with the ED and Medical Director to ensure timely, appropriate referrals and effective transitions of care.

• Accurately document patient assessments, physician recommendations, goals-of-care outcomes, enrollment status, and other required information in the medical record and designated tracking tools.
• Apply current Medicare hospice, palliative care, and CMS requirements while maintaining current knowledge of serious illness communication, advance care planning, and evidence-based palliative care practices.