Care Transition Navigator - High-Impact Home Health Coordinator

Vitalcaring-Group; Houston (TX); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

401(k) with company match

Employee referral program

Tuition and CE reimbursement

Flexible Spending Accounts

Job summary

VitalCaring is hiring a Care Transition Navigator (CTN) in Houston to coordinate hospital-to-home transitions. You will work field-based with hospital teams, coordinating patient care, safety plans, and readmission reduction strategies.

This role requires active RN/LVN/LPT licensure and at least two years of clinical experience, preferably in home health or post-acute settings, with strong communication and organizational skills.

Qualifications

• Active RN, LVN/LPN, or PT license in the state of employment (or compact eligibility)
• 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 with patients, families, and clinicians
• Excellent organization with ability to manage multiple patients and priorities
• Proficiency with EMR systems and basic computer applications
• Valid driver’s license and reliable transportation

Responsibilities

• Serve as liaison between hospital teams, patients, and VitalCaring clinicians for transitions to home health
• Conduct bedside assessments to identify clinical needs and barriers to discharge
• Collaborate with case managers and physicians to develop safe transition plans
• Drive timely admissions by coordinating referrals and handoffs to home health
• Build trusted relationships with hospital partners through consistent communication
• Complete post-discharge follow-up within 48 hours and coordinate with primary care
• Collaborate with internal teams to improve outcomes and reduce readmissions

Skills

RN/LVN/PT license

Clinical experience

Discharge planning

Care coordination

Interdisciplinary teamwork

Education

Nursing license (RN/LVN/LPT)

Tools

EMR systems

HCHB EMR

Job description

VitalCaring is hiring a Care Transition Navigator (CTN) in Houston to coordinate hospital-to-home transitions. You will work field-based with hospital teams, coordinating patient care, safety plans, and readmission reduction strategies.

This role requires active RN/LVN/LPT licensure and at least two years of clinical experience, preferably in home health or post-acute settings, with strong communication and organizational skills.