Transitional Care Specialist

TRANSITIONAL CARE SPECIALIST

Liberty Cares With Compassion

At Liberty Home Care we know that following an illness, trauma or surgery, the ability to recover at home can greatly improve patient outcomes. Our healthcare professionals are dedicated to offering recovery with independence to our patients.

• Facilitate Transitional Care initiatives that promote hospice access across the organization. Collects organizational data to generate reports on current and projected work volume and for multiyear projections.
• Swiftly identifies, resolves, trends, and reports root causes of transitional care issues while understanding the importance of urgency in developing and implementing leading practice solutions to achieve client goals. Assists in the resulting development of organizational educational needs as needed or directed.
• Communicates continuously with facility administration or designee to ensure coordination of information and maintain accuracy of Transitional Care planning.
• Supports and assists Business Development Team members with the development of Educational programs for Referral Sources and provides Clinical Training on the Transitional Care Program.
• Serves as a resource to review and consult available patient information related to the case to determine if hospice care is appropriate across the enterprise.
• Coordinates and communicates with hospice agency leadership and referral sources to promote Transitional care coordination and a timely admission process.
• Provides company-wide training and support as needed.
• Confers with the Medical Director or attending physician regarding patient hospice determination criteria.
• When needed, obtain physician orders and Certification of Terminal Illness, as well as other admission documentation as required.
• Serves as a Clinical Liaison between assigned territories with coordination of referrals/admission.
• Completes an initial review of records and discuss hospice services with patients and families to determine hospice needs. Transitional Care Specialist is able to assist with ordering DME and completion of consents for hospice admission as needed
• Serves as a hospice resource for the assigned territory to promote the continuum of care.
• Uses health assessment data to determine nursing diagnosis.
• Through the use of Liberty’s Business Intelligence Software assists the marketing department with data analysis.
• Performs other related duties as required and assigned.

• Bachelor’s Degree or Clinical License Required. At least 5 years of healthcare experience within the Post-Acute Industry.
• Good organizational and time management skills.
• Ability to interact well with co-workers while maintaining strict confidentiality.
• Ability to work with limited direction and fluid autonomy while effectively working within a team.
• Must demonstrate analytical skills for market intelligence management and targeted execution of measures.
• Ability to implement necessary changes with all internal and external partners involved with Transitional Care.
• Must possess strong attention to detail and pleasant telephone manner.
• Proficient knowledge of computers, word processing, especially Word and Excel.
• Strong administrative and keyboarding skills. Must have a valid drivers’ license.

Visit  for more information. Background checks/drug-free workplace. EOE.