Care Transition Navigator — Field-Based Health Coordination

Vitalcaring-Group; Port Charlotte (FL); On-site; USD 65,000 - 85,000; Full time

Benefits offered by this job

Medical/Dental/Vision

Virtual care/mental health

FSA & HSA

Supplemental life insurance

401(k) match

Employee referrals

Prepaid legal services

Identity theft protection

Work-life balance

Paid time off

Education reimbursement

Job summary

VitalCaring seeks a Care Transition Navigator (CTN) to ensure safe hospital-to-home transitions. This field-based role collaborates with hospital teams, case managers, physicians, patients and families to coordinate care, reduce readmissions, and improve outcomes.

You will conduct bedside assessments, develop transition plans, and drive timely admissions into home health services while building strong relationships with hospital partners.

Qualifications

• Active RN, LVN/LPN, or PT license in the state of employment.
• 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.

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.

Skills

Active RN/LVN/LPT license

EMR proficiency

Excellent communication

Tools

EMR systems

Job description

VitalCaring seeks a Care Transition Navigator (CTN) to ensure safe hospital-to-home transitions. This field-based role collaborates with hospital teams, case managers, physicians, patients and families to coordinate care, reduce readmissions, and improve outcomes.

You will conduct bedside assessments, develop transition plans, and drive timely admissions into home health services while building strong relationships with hospital partners.