Care Transition Navigator — Field Health Coordination

VitalCaring Group; Port Charlotte (FL); Hybrid; USD 65,000 - 85,000; Full time

Benefits offered by this job

Medical/Dental/Vision coverage

401(k) with company match

Tuition and CE reimbursement

Generous paid time off

Job summary

VitalCaring Group is seeking a Care Transition Navigator (CTN) – Home Health to ensure smooth hospital-to-home transitions. You will work field-based within hospital systems, coordinating with case managers, physicians, patients, and families to reduce readmissions and improve outcomes.

This role blends clinical insight with care coordination and referral management to support patient success and agency growth. Strong EMR skills and patient-focused communication are required.

Qualifications

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

Responsibilities

• Serve as the primary liaison between hospital teams, patients, and VitalCaring clinicians to ensure seamless transitions from hospital to home health.
• 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

RN license

LVN/LPN license

PT license

EMR proficiency

Clinical coordination

Communication skills

Time management

Tools

EMR systems

Job description

VitalCaring Group is seeking a Care Transition Navigator (CTN) – Home Health to ensure smooth hospital-to-home transitions. You will work field-based within hospital systems, coordinating with case managers, physicians, patients, and families to reduce readmissions and improve outcomes.

This role blends clinical insight with care coordination and referral management to support patient success and agency growth. Strong EMR skills and patient-focused communication are required.