Care Transition Navigator

VitalCaring Group; Independence (MO); Presencial; USD 70 000 - 100 000; Tempo integral

Resumo da oferta

VitalCaring Group is seeking a Care Transition Navigator (CTN) to operate field-based, hospital-focused care coordination, guiding patients from admission to home health after discharge. You will partner with hospital teams, physicians, and families to develop transition plans, coordinate referrals, and reduce readmissions, while ensuring timely post-discharge follow-up.

This role requires clinical licensure, strong communication, and organizational skills to support patient outcomes and agency

Qualificações

• Active RN, LVN/LPN, or PT license in the state of employment.
• Minimum of two years of clinical experience; home health or post-acute experience preferred.
• Experience in healthcare coordination, case management, clinical care, or hospital-based roles.
• Strong understanding of patient care transitions, discharge planning, or post-acute services.
• Excellent communication skills with the ability to engage patients, families, and clinicians effectively.

Responsabilidades

• Serve as the primary liaison between hospital teams, patients, and VitalCaring clinicians to ensure seamless transitions from hospital to home
• Conduct bedside assessments to identify clinical needs, risk factors, and barriers to successful discharge
• Partner with case managers and physicians to develop and execute safe, patient-centered transition plans
• Drive timely admissions by coordinating referrals and ensuring smooth handoffs into home health services
• Build strong, trusted relationships with hospital partners through consistent communication and follow-through
• Complete post-discharge follow-up within 48 hours and ensure timely primary care coordination
• Collaborate with internal teams and support initiatives focused on improving outcomes and reducing readmissions

Conhecimentos

RN license

LVN/LPN license

PT license

Clinical experience 2+ years

Home health / post-acute

EMR proficiency

Driver's license

Ferramentas

Homecare Homebase (HCHB)

Descrição da oferta de emprego

Care Transition Navigator (CTN) – Home Health

Field-Based | Hospital-Focused | Patient Transition & Care Coordination

Role Overview

The Care Transition Navigator plays a critical role in ensuring safe, seamless transitions from the hospital to home health care. This position works directly within assigned hospital systems, partnering with case managers, physicians, patients, and families to coordinate care, reduce readmissions, and improve patient outcomes.

This is a high-impact, relationship-driven role that blends clinical insight, care coordination, and referral management to support both patient success and agency growth.

Key Responsibilities

• Serve as the primary liaison between hospital teams, patients, and VitalCaring clinicians to ensure seamless transitions from hospital to home
• Conduct bedside assessments to identify clinical needs, risk factors, and barriers to successful discharge
• Partner with case managers and physicians to develop and execute safe, patient-centered transition plans
• Drive timely admissions by coordinating referrals and ensuring smooth handoffs into home health services
• Build strong, trusted relationships with hospital partners through consistent communication and follow-through
• Complete post-discharge follow-up within 48 hours and ensure timely primary care coordination
• Collaborate with internal teams and support initiatives focused on improving outcomes and reducing readmissions

Required Qualifications

• Active RN, LVN/LPN, or PT license in the state of employment (or compact eligibility, if applicable)
• Minimum of two (2) years of clinical experience; home health or post-acute experience preferred
• Experience in healthcare coordination, case management, clinical care, or hospital-based roles
• Strong understanding of patient care transitions, discharge planning, or post-acute services
• Demonstrated ability to build relationships with healthcare providers and interdisciplinary teams
• Excellent communication skills with the ability to engage patients, families, and clinicians effectively
• High level of organization with the ability to manage multiple patients and priorities simultaneously
• Proficiency with EMR systems and basic computer applications
• Valid driver’s license and reliable transportation

Preferred Qualifications

• Experience in home health, hospice, or post-acute care
• Background working within hospital systems (case management, discharge planning, or bedside coordination)
• Knowledge of CMS guidelines and readmission reduction strategies
• Familiarity with Homecare Homebase (HCHB) or similar EMR systems

Work Environment & Expectations

• Field-based role with regular presence in assigned hospitals and healthcare facilities
• High-touch, patient-facing position requiring strong interpersonal and clinical communication skills
• Fast-paced environment requiring adaptability, critical thinking, and proactive follow-through
• Performance expectations tied to both patient outcomes and successful care transitions/admissions
• Requires strong time management to balance hospital coordination, patient interaction, and documentation