Care Transition Coordinator Hospice

The Care Transition Coordinators primary responsibility is to facilitate a seamless transition for patients
discharging from a facility setting to the care of an LHC Group hospice agency. The CTC will verify hospice orders,
assess patient needs, and ensure continuity of care and the agency's ability to meet the needs of the patient as
they transition out of the hospital. This position will also provide oversight for any hospice patients that require
general inpatient care in the assigned facility. The CTC will strive to support, educate and collaborate with facility
staff on the provision of hospice services.

• Successfully executes a weekly, monthly, and quarterly strategy to increase market share through key account development including prospecting diversification and call frequency routing. Plans activity to maximize territory coverage of both existing and prospective accounts
• Responsible for achievement of admission goals|expectations as established at hire or at review of annual agencybudget goals.
• Assists the LHC Group agency with the preparation for accepting care of the patient post discharge from thehospital.
• Coordinates other services for the patient with ancillary service providers (DME|Infusion).
• Coordinates the gathering, organization and transfer of necessary information to the applicable LHC Groupagency staff.
• Ensures the availability of a attending physician to follow the patients care in the home or the transfer of primary care to the hospice medical director.
• Assists the Administrator with execution of contracts for facility based services for hospice patients.
• Explains hospice services and agency procedures to the patient and his|her family members.
• Involves the family|caregivers in the educational process and assesses post-discharge educational|coachingneeds.
• Knowledgeable about state specific admission criteria and timelines for admission.
• Monitors the status of all patients receiving Respite or General Inpatient Care and facilitate thecommunication between the agency|hospital|physician.
• Participate in bi-weekly IDG meetings, as necessary to give an update regarding accounts, customer needs, and progress towards agency growth strategies
• Participates in weekly one-on-one meetings with Administrator
• Responsible for the initial medication reconciliation with appropriate hand off and communication to visiting staff.
• Schedules a follow-up phone call to the FCC in the system 48 hours post admit.
• Serves as a liaison between the LHC Group agency, the facility care setting and the referring physician
• Serves as an educational resource for hospital staff and physicians regarding the hospice benefit and relatedregulations, including, consulting with hospital staff or physicians regarding an individual patients suitability forhospice benefit provided there is NO contact with the patient or the patients family members prior to the referral tohospice
• Visits and communicates with the patient in the hospital to obtain necessary information to facilitate the transfer.
• All other duties as assigned.

• Must have one year hospice experience or one year of hospital case management experience.
• Must have current Registered Nurse (RN) or Licensed Practical Nurse (LPN) or Social Worker (SW) licensure in state of practice.
• Excellent organizational skills.
• Excellent verbal and written communication skills.
• Must have thorough understanding of hospice qualifying criteria and coverage guidelines.
• Proficient computer skills.
• Current CPR, driver's license, valid vehicle insurance and access to a dependable vehicle, or public transportation.