Transitional Care Navigator

About the role

Addus Home Care / Alamo Hospice is seeking a Hospice Transitional Care Navigator. The position is based in the assigned market (San Antonio, TX).

Responsibilities

• Build upstream-referral relationships and transition hospice referrals from physicians and other referral sources.
• Serve as hospice clinical consultant and educator, acting as extensions of hospital and physician care team.
• Review hospital clinical documentation/EMR/HCHB, engage with patients and providers to build clinical patient profiles and clinical-admission-assessments and identify decline patterns (e.g., frequent hospitalizations, functional deterioration).
• Consult with hospital care teams by sharing clinical profiles and educating on hospice appropriateness.
• Identify attending and consulting providers associated with referred patients – to provide patient assessment, eligibility and discharge education and awareness.
• Collaborate with field sales representatives to schedule and conduct consultative meetings with external care teams.
• Initiate and maintain care team workflows for patient information/clinical assessment and documentation, consultation/education planning and delivery, external and internal meetings and preparations.
• Identify trends, needs, and partnership opportunities for earlier hospice engagement.
• Foster effective and trusted relationships with external care teams to improve patient outcomes and enhance end-of-life satisfaction.
• Communicate clearly and consistently with hospital leadership and care coordination teams.
• Effectively organize, track and prioritize high-value patient comprehensive reviews.
• Meet all productivity requirements, including timely review of medical records, hospital and provider consultation and education.
• Promote a collaborative and team-focused environment.
• Uphold hospice policies, privacy practices, and ethical guidelines.
• Professionally represent the organization in all hospitals, community, and partner interactions.
• Collaborate cross-functionally with internal hospice departments and leadership teams.
• Perform other duties as assigned.

Skills

• Self‑driven with a hunter‑sales mentality and drive.
• Strong sense of curiosity, resilience, and adaptability.
• Ability to find, develop, build, and leverage referring‑relationships.
• Experienced communicator.
• Strategic thinking and problem‑solving.
• Focus on expanding value for patients and the organization.

Qualifications

• Bachelor’s degree in marketing, business administration, or related field preferred; equivalent experience/training considered.
• Licensed as a registered nurse in the state of practice preferred.
• Minimum of two years relevant experience.
• Ability to make independent decisions when circumstances warrant.
• Ability to deal tactfully with patients, family members, visitors, agency personnel, and the public.
• Knowledgeable of quality assessment and assurance procedures.
• Valid driver’s license and proof of insurance required.

Benefits

• Comprehensive benefits (medical, dental, vision, life/AD&D, disability), effective first of the month.
• 401(k) retirement plan with a generous company match.
• Generous time off accruals.
• Paid holidays.
• Mileage reimbursement.
• Tuition reimbursement.
• Employee Referral Program.
• Merit increases.
• Employee discount programs.
• Work/life balance.
• Recognized as the top healthcare company on Indeed's 2024 Top 100 Work Wellbeing Index.