Life Transitions Benefit Counselor

Job Description Summary

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We are excited to announce an opening for a Life Transitions Benefit Counselor! The Life Transitions Benefit Counselor is a licensed clinical professional responsible for guiding patients and families through end-of-life care decisions within a value-based care model. This role serves as a critical bridge between patients, caregivers, internal care teams, and hospice partners to ensure timely, appropriate, and compassionate transitions to hospice care.

Leveraging clinical expertise and strong communication skills, this individual manages the full hospice referral lifecycle while supporting informed decision-making and aligning care with patient goals and preferences.

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How will you make an impact & Requirements

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Key Responsibilities:

• Serve as the primary day-to-day clinical point of contact for hospice partners, ensuring strong collaboration and seamless care coordination.

• Coordinating Monthly Joint operating meetings with local hospices in collaboration with MPG clinical and administrative teams.

• Receive, triage, and manage hospice referrals from Primary Care Providers (PCPs) and Care Management teams, prioritizing based on clinical need and urgency.

• Assess and validate hospice eligibility in alignment with hospice partner criteria, using clinical judgment and available patient data.

• Lead initial and ongoing goals-of-care conversations with patients, families, and caregivers, providing education on prognosis, hospice services, and end-of-life options in a compassionate, patient-centered manner.

• Own and drive the end-to-end hospice referral process—from initial patient engagement through hospice acceptance—ensuring timely progression and clear communication across all stakeholders.

• Maintain proactive engagement with eligible but not yet ready patients, using clinical insight and relationship-building to revisit conversations as conditions evolve.

• Work closely with Clinical Operations and Healthcare Economics to actively track and quantify opportunity. This includes building, maintaining, and routinely reviewing a dashboard that clearly outlines performance, gaps, and targets. Actively use information to drive alignment, and ensure action is being taken at the care team level.

• Connect patients and families who are not eligible for hospice to other Millenium and community resources

• Navigate and operate effectively within the Millennium Physician Group ecosystem, understanding patient flow, referral pathways, and internal coordination across clinical teams.

Requirements

• Active, unrestricted licensure in one of the following:

  • Registered Nurse (RN)

  • Licensed Clinical Social Worker (LCSW)

  • Social Worker (SW) or equivalent clinical licensure

• Experience with home visits required

• 3+ years of experience in hospice, palliative care, care management, or complex care coordination

• Strong understanding of hospice eligibility criteria, end-of-life care planning, and goals-of-care discussions

• Demonstrated ability to navigate sensitive conversations with empathy, clarity, and professionalism

• Experience working within a value-based care or managed care environment preferred

About Millennium Physician Group:

Formed in 2008 and headquartered in Fort Myers, Florida, with offices in Florida, North Carolina, Georgia, and Texas, Millennium Healthcare is the largest independent physician group in the state of Florida and one of the largest in the United States. At Millennium Physician Group, our employees are the foundation of our success. Our promise is to provide you with the tools to do your job successfully, as well as providing a team atmosphere that empowers you to seek better ways to deliver care to our patients and their families. We also promise to care for you as an individual and help you grow in your role.

What We Offer:

• Health, Dental, and Vision Insurance

• 401(K) Retirement Plan with Matching

• Short & Long-Term Disability

• Employer-Paid Life Insurance

• Paid Time Off, Floating Holidays, and Paid Major Holidays

• Employee Assistance Program (EAP)

• and much more!

How to Apply:

ARE YOU READY TO JOIN OUR TEAM? We understand your time is valuable, and that is why we have a very quick and easy application process. If you feel that you are right for this position, please fill out our initial 3-minute, mobile-friendly application so that we can review your information. We look forward to meeting you!