Care Transitions Specialist

Care Transitions Specialist

At HCS, hospice is about more than end-of-life care - it's about ensuring every eligible patient finds their way to the support they deserve, at the right time. As a Care Transitions Specialist, you'll serve as the vital link between HCS and the hospitals, assisted living facilities, and skilled nursing facilities across our region. You'll build lasting relationships with referral partners, guide families through difficult transitions, and work side-by-side with our clinical team to make sure no patient falls through the cracks. If you're a skilled clinician or social worker who thrives on relationship-building, patient advocacy, and making meaningful community impact, we'd love to connect.

Responsibilities

• Partner with hospitals, assisted living facilities, and skilled nursing facilities to identify and support clinically eligible hospice patients - in facility or transitioning home
• Consult with patients, families, nurses, discharge planners, and physicians to develop coordinated care plans upon referral to HCS
• Build and maintain new referral relationships with healthcare professionals, facilities, and continuing care units throughout our service area, including West Lebanon and Claremont
• Educate referral partners and community members through approved hospice in-services and informational presentations
• Facilitate communication between referral sources and the HCS hospice team to streamline admissions and ensure patients receive timely access to their benefits
• Meet regularly with the team to identify patients who would benefit from hospice services
• Track key metrics, volume goals, timelines, and project outcomes and report on them regularly
• Remain current with changes in hospital and inpatient care environments and communicate updates to HCS staff

Why Join Us?

• High-impact work: You'll be the person who ensures patients and families find their way to compassionate hospice care at the moment they need it most - that's an extraordinary thing to do every day.
• Collaborative team: You'll work alongside dedicated clinicians, a supportive Palliative Care team, and a Director of Growth who believes in your success.
• Regional reach: This role gives you the opportunity to build real, lasting relationships across the Monadnock Region and beyond - you'll become a trusted name in our healthcare community.
• Mission-driven organization: HCS has served southwestern New Hampshire for decades. We're rooted here, we're growing, and we're committed to the people we serve - and to you.

Requirements

• Graduate of approved program. Bachelor of Science Degree – Nursing or Social Work
• Three (3) years of satisfactory experience in community health in a licensed and/or Medicare Certified Program. Recent acute hospital experience and supervisory experience; 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 Nurse, if appropriate
• Valid driver's license. Have access to an automobile during working hours that meets the State of New Hampshire registration regulations and auto liability insurance.
• Must be able and willing to learn to utilize a portable electronic field device. Must be able to 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. Clinical services include visiting nurses, physical and occupational therapies, social work, and home health aides. Hospice at HCS offers end-of-life care and grief support for patients and families wherever they call home, including assisted living and nursing homes. HCS is unique in the wide range of community services offered, including Healthy Starts family services, Meals on Wheels and senior dining, City Express and Friendly Bus transportation, and Nurse Is In foot care clinics. HCS is Medicare certified and licensed by the State of New Hampshire.