Care Transition Navigator: Hospital to Home Champion

VitalCaring Group; Orlando (FL); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Medical, Dental, Vision coverage

Virtual care and mental health support

FSA/HSA

401(k) with company match

Tuition reimbursement

Paid time off

Job summary

VitalCaring seeks a Care Transition Navigator (CTN) to coordinate hospital-to-home health transitions and reduce readmissions. This field-based role partners with case managers, physicians, patients, and families to ensure smooth care handoffs and optimal outcomes.

You will perform bedside assessments, develop discharge plans, and facilitate timely admissions into home health services. A licensed clinical professional with 2+ years of experience and EMR proficiency is required, along with a

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
• 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

RN/LVN/LPN/PT license

Clinical experience 2+ years

EMR proficiency

Valid driver’s license

Job description

VitalCaring seeks a Care Transition Navigator (CTN) to coordinate hospital-to-home health transitions and reduce readmissions. This field-based role partners with case managers, physicians, patients, and families to ensure smooth care handoffs and optimal outcomes.

You will perform bedside assessments, develop discharge plans, and facilitate timely admissions into home health services. A licensed clinical professional with 2+ years of experience and EMR proficiency is required, along with a