Care Transition Navigator – Hospital-to-Home Impact

VitalCaring Group; Norman (OK); Sur place; USD 65 000 - 90 000; Plein temps

Avantages offerts par ce poste

Medical coverage

Dental coverage

Vision coverage

Virtual care

Mental health support

FSA

HSA

Life insurance

401(k) matching

Referral program

Prepaid legal

Identity theft protection

Paid time off

Education reimbursement

Résumé du poste

VitalCaring Group is seeking a passionate Care Transition Navigator (CTN) to ensure safe, seamless hospital-to-home health transitions. You will collaborate with case managers, physicians, patients, and families to coordinate care, reduce readmissions, and improve outcomes in a field-based setting.

The role blends clinical insight, care coordination, and referral management to support patient success and agency growth with a strong emphasis on timely admissions and high-quality patient care.

Qualifications

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

Responsabilités

• 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

Connaissances

RN license

LVN/LPN license

PT license

Outils

EMR systems

Description du poste

VitalCaring Group is seeking a passionate Care Transition Navigator (CTN) to ensure safe, seamless hospital-to-home health transitions. You will collaborate with case managers, physicians, patients, and families to coordinate care, reduce readmissions, and improve outcomes in a field-based setting.

The role blends clinical insight, care coordination, and referral management to support patient success and agency growth with a strong emphasis on timely admissions and high-quality patient care.