Palliative Care Transitions Specialist (Remote)

About Us
Ennoble Care is a mobile primary care, palliative care, and hospice service provider with patients in New York, New Jersey, Maryland, DC, Virginia, Oklahoma, Kansas, Pennsylvania, Texas, Florida, and Georgia. Ennoble Care’s clinicians go to the home of the patient, providing continuum of care for those with chronic conditions and limited mobility. Ennoble Care offers a variety of programs including, remote patient monitoring, behavioral health management, and chronic care management, to ensure that our patients receive the highest quality of care by a team they know and trust. We seek individuals who are driven to make a difference and embody our motto, “To Care is an Honor.” Join Ennoble Care today!
Job Summary:
The Palliative Care Transitions Specialist manages patients through the palliative continuum - from referral and eligibility screening, through active palliative care coordination, to timely transitions into hospice or other appropriate levels of care. This is a transitions-focused role: the Specialist identifies palliative-appropriate patients early, keeps care moving across providers, patients, families, and facilities, and ensures goals-of-care and hospice conversations happen at the right time. The ideal candidate is clinically grounded, compassionate, highly organized, and comfortable working across multiple systems and markets.
Key Responsibilities:
Referral & Eligibility Screening
Review incoming referrals for palliative appropriateness - diagnosis, prognosis, and treatment status - and classify as appropriate, borderline, or insufficient information; escalate unclear PCP notes for provider review.
Confirm patient eligibility and coverage windows before care is initiated.
Ensure referrals are correctly tagged as palliative in Zoho so intake prioritizes them, and expedite urgent referrals through the appropriate market channels and scheduling contacts.
Complete chart reviews using the standard review template, consistently across reviews.
Care Transitions
Own the transition from palliative care to hospice: identify patients approaching hospice eligibility, coordinate goals-of-care and hospice discussions, and coordinate handoffs between palliative providers, hospice, and facilities.
Coordinate urgent palliative-care and telehealth visits for goals-of-care and hospice conversations.
Track patients across transition points so no one falls through the gaps between palliative, hospice, and primary care.
Care Coordination
Complete individualized care plans and perform care management using Ennoble Care's EMR (OA/Order & MatrixCare and related systems).
Serve as a point of contact between providers, patients/families, SNFs, and partner facilities to keep care plans complete, accurate, and moving.