Care Transition Nurse

Monroe, Louisiana, United States Full-time

Position: Care Transition Nurse

Location: Monroe


Job Description Summary

  • Coordinates the care transition of the patient including gathering chart information.
  • Responsible for completing part or all of the admission process for hospice eligible patients.
  • Collaborates with referring and/or attending physician to ensure hospice eligibility.
  • Collaborates with referring and/or attending physician to establish the Plan of Care.
  • Provides daily GIP visit services or respite care when patient resides in the hospital.
  • Maintains patient clinical records according to hospice and hospital policy.
  • Assists in problem resolution with all personnel as well as families/patients/community.
  • Provides consistency, predictability and visibility in the hospital setting.
  • Provides education and in-services to hospital and hospice personnel.Partners with the sales team to establish and maintain positive working relationships with current and potential referral and payer sources to bring a greater understanding of the hospice philosophy and support patients and families that desire our care and are eligible.Assists in case management of patients outside of the hospital when requested.
  • Promotes customer service at all times in all settings.
  • Participates in after hours on call schedule as assigned.                 
  • Participates in Interdisciplinary Team Meetings when necessary.
  • Complies with accepted professional standards and principles.
  • Participates in the Quality Assessment Performance Improvement program.
  • Knowledge of and adherence to all policy and procedures.




  • Registered nurse with current licensure with no restrictions to practice professional nursing in the state.
  • Graduate of an accredited school of nursing with a BSN degree is preferred
  • Previous experience in both the hospice and hospital setting preferred.