Care Transition Navigator – Hospital-to-Home Health

VitalCaring Group; Blanchard (OK); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Medical, Dental, Vision

Virtual care and mental health support

FSA/HSA

401(k) with company match

Employee referral program

Prepaid legal services

Identity theft protection

Generous paid time off

Education reimbursement

Job summary

VitalCaring Group in the United States is seeking a Care Transition Navigator to ensure safe hospital-to-home transitions. You will collaborate with hospital teams, case managers, physicians, patients, and families to coordinate care and reduce readmissions.

This field-based role blends clinical insight with care coordination and referral management, offering growth opportunities, competitive benefits, and a supportive team dedicated to improving patient outcomes.

Qualifications

• Active professional healthcare license in the state of employment (RN/LPN/LPT).
• Minimum of 2 years clinical experience; home health or post-acute experience preferred.
• Experience in healthcare coordination, case management, or hospital-based roles.
• Strong understanding of patient care transitions and discharge planning.
• Excellent communication and organizational skills with ability to manage multiple patients.

Responsibilities

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

Skills

Active RN license

Clinical coordination

Discharge planning

Communication

Organization

Education

RN/LPN/LPT license in state

2+ years clinical experience

Tools

EMR systems

HCHB (Homecare Homebase)

Job description

VitalCaring Group in the United States is seeking a Care Transition Navigator to ensure safe hospital-to-home transitions. You will collaborate with hospital teams, case managers, physicians, patients, and families to coordinate care and reduce readmissions.

This field-based role blends clinical insight with care coordination and referral management, offering growth opportunities, competitive benefits, and a supportive team dedicated to improving patient outcomes.