Job Description

This full-time professional role provides comprehensive education, guidance, and supportive services to pediatric patients and their families referred to or enrolled in the Transitions Kids (TK) Program. The position collaborates closely with inpatient and outpatient multidisciplinary care teams and referral sources to promote continuity, coordination, and quality of care across settings.

Key Responsibilities

• Serve as the primary point of contact for patients referred to Transitions Kids (TK), completing admission visits and follow-up communications.
• Partner with inpatient hospital teams to clarify TK’s role in post-discharge care planning.
• Build and maintain collaborative relationships with community providers, participating in team and/or family meetings to promote understanding of TK services.
• Identify appropriate referrals and educate stakeholders regarding the scope and eligibility of TK services.
• Collaborate closely with TK team members to ensure seamless transitions from hospital to home or other care settings.
• Complete comprehensive needs assessments and contribute to program development and growth initiatives.
• Provide after-hours coverage as required, including home visits to support symptom management or end-of-life care.
• Deliver all services in accordance with agency policies, professional standards, and applicable regulatory requirements.

Responsibilities – What You Do

Patient & Family Support

• Provide compassionate, family-centered emotional support to pediatric patients and families affected by serious illness or loss across all stages of care, including during inpatient hospitalizations.
• Deliver crisis intervention and bereavement support, participating in grief services in collaboration with other TK Pediatric Palliative Care Specialists.

Education & Advocacy

• Educate patients, families, healthcare providers, referral sources, and care teams on the purpose, role, scope, and limitations of Transitions Kids (TK) services.
• Clearly explain distinctions and areas of overlap between pediatric palliative care and hospice to support informed decision-making.

Care Coordination & Collaboration

• Work collaboratively with the TK Interdisciplinary Group (IDG) to assess needs, establish care goals, determine appropriate levels of care, and coordinate services.
• Communicate effectively with durable medical equipment providers, pharmacies, transportation services, and other community partners to support patient care needs.
• Identify and connect patients and families with appropriate community resources.

Clinical Care & Documentation

• Plan, provide, oversee, and document safe, ethical, and compassionate care in alignment with physician orders, agency policies, and procedures.
• Complete timely initial and ongoing assessments of patient and family needs, documenting care plans and interventions.
• Apply professional judgment, in collaboration with the IDG, to individualize care plans responsive to patient and family goals and evolving needs.

Compliance & Quality Improvement

• Provide and document end-of-life education for facility staff, patients, and families in accordance with CMS Conditions of Participation.
• Participate in quality and performance improvement initiatives and identify opportunities for clinical or operational enhancement.
• Maintain current knowledge of discipline-specific best practices, regulatory requirements, and professional standards.

Professional Development & Team Engagement

• Engage in ongoing professional development to maintain competencies and enhance clinical expertise.
• Manage time, caseloads, resources, and technology efficiently and professionally.
• Support onboarding, orientation, and training of new staff and students across disciplines.
• Actively participate in TK team meetings, case conferences, and collaborative planning.
• Perform additional duties as assigned by the Director of Transitions Kids and/or Team Lead.

Expectations – How You Do It

• Demonstrate TK Core Values in all interactions with patients, families, colleagues, and community partners.
• Comply with Transitions LifeCare (TL) and Transitions Kids (TK) policies, procedures, and guidelines.
• Adhere to CMS and state regulations and applicable social work standards of practice.
• Uphold NHPCO Ethical Practices and, as applicable, the National Association of Social Workers (NASW) Code of Ethics.

Requirements – What You Need

Education & Licensure

• Master of Social Work (MSW) from an accredited institution.
• Licensed Clinical Social Worker (LCSW) required or obtained within two years of hire.
• Advanced Palliative and Hospice Social Worker–Certified (APHSW-C) preferred.

Experience

• Minimum of one year of experience in a healthcare-related field.
• Prior experience in hospice and/or pediatric care preferred.
• Experience facilitating goals-of-care discussions and/or completing advance directives preferred.

Skills & Competencies

• Strong interpersonal and communication skills with the ability to engage patients, families, interdisciplinary teams, physicians, facility staff, and leadership.
• Ability to educate families about TK services and collaborate in establishing care goals aligned with patient and family values.
• Demonstrated ability to build trust with patients, families, and community partners.
• Capacity to work both independently and collaboratively in hospital, clinic, and community settings.
• Knowledge of reimbursement sources, including Medicare and Medicaid regulations, licensure requirements, and accreditation standards.
• Proficiency with computers and electronic documentation systems.
• Bilingual skills preferred, particularly Spanish.

Physical & Operational Requirements

• Valid North Carolina driver’s license, reliable transportation, and current automobile insurance.
• Ability to travel throughout the service area and enter patient homes and healthcare facilities.
• Ability to lift and/or carry items weighing up to 50 pounds.
• Sensory abilities sufficient for conducting assessments, effective communication, and documentation.
• Availability to work flexible hours, including evenings, weekends, and holidays, in accordance with employee guidelines.