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Referral Management and Transitions of Care Manager

Lawrence, MA

Hospital And Health Care
Job ID
Job Category
Merrimack Valley Hospice – Lawrence
Work Address
360 Merrimack St. Ste. 425 Lawrence, MA 01843

Company Description

Care at Home is a proud member of Tufts Medicine, a health system that is rethinking how academic and community centers, local and national businesses, and technology and service innovators can all work together. So that clinicians can deliver expert care where it’s needed most. And, so that we can bring wellness back to health care, one person at a time.  

Job Description

The Referral Management and Transitions of Care Manager assures that the daily workflow of the Referral Department and Transitions of Care is progressive and consistent. This position manages expectations of referral sources and customer service issues with the referral community and problem solves with clinical teams to remove barriers to admit patients to the agency. The Referral Management and Transitions of Care Manager sets priorities with respect to referral processing, triages clinical issues and/or requests, delegates appropriate tasks to Referral Management Specialists and Referral Specialists, and acts as a resource to the Referral Department team, oversees team of Care Coordinator’s in the hospital and community setting.

Essential Functions:

  • Provides effective guidance to entire Referral Department and Transitions of Care team, clinical and administrative team regarding clinical and administrative issues, prioritization and workflow management.
  • Collaborates with Director of Referral Management and Transitions of Care and Human Resources to effectively interview and make recommendations for qualified candidates for vacant Referral and Liaison Department positions.
  • Collaborates with Director of Referral Management and Transitions of Care to provide feedback regarding Referral Management Specialist, Referral Specialist performance, Transitions of Care staff, their accounts, growth and account management.
  • Works cooperatively with the Director of Referral Management and Transitions of Care to improve processes and efficiencies within the department.
  • Identifies, reports, and acts on referral source and referral request concerns by communicating with department Director, as well as other agency leaders as appropriate.
  • Acts as a role model and mentor for Referral Department and Transitions of Care team, as well as new employees.
  • Provides warm hand-off communication to Referral Nurse Specialist assuming lead role, and others as appropriate.
  • Serves as a resource for referral sources and the community regarding services provided, third party regulations, determination of home care eligibility, and appropriateness for home health or hospice.
  • Provides resource information if patient/client is not eligible or not appropriate for home care or hospice.
  • Gathers necessary information and uses clinical expertise to manage timely and accurate referral processing, with a focus on medically complex referral requests and works with transition of care team to ensure safe and timely discharges and documentation.
  • Reviews admitting department operations and systems to ensure compliance with applicable standards.
  • Provides input to strategic decisions on agency growth that affect the functional area of responsibility.
  • Capable of resolving escalated issues arising from operations, referral management and transitions of care and requiring coordination with other departments.

Position Type/Expected Hours of Work & Travel

This is a full-time position, and days and hours of work are Monday through Friday, 10 a.m. to 6:30 p.m. with some flexibility based on position. This position has overall supervisory responsibility seven days a week based on department needs.


  • Current LPN or RN license in Massachusetts and New Hampshire required.
  • Home Health and Hospice experience preferred.
  • Experience in referral management and transitions of care preferred.
  • Previous management experience required.

Additional Information

Care at Home is an equal opportunity employer- M/F/Veteran/Disability. 


AAP/EEO Statement

Home Health Foundation is an Equal Opportunity Employer and dedicated to the goal of building a diverse and inclusive workplace that reflects the patient population in which we serve. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, disability, protected veteran status, genetic information, or any other characteristic protected by applicable law. Home Health Foundation is especially interested in candidates who, through their service, training and experience, will contribute to the diversity and excellence of our health care community.

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

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