Care Transition Navigator: Hospital-to-Home Impact

VitalCaring Group; Venice (FL); On-site; USD 65,000 - 85,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Virtual care

Health Savings Account (HSA)

401(k) match

Employee referral program

Prepaid legal

Identity theft protection

Generous paid time off

Tuition reimbursement

Job summary

VitalCaring Group is seeking a Care Transition Navigator (CTN) for field-based hospital-to-home coordination. You will work with hospital teams, patients, and clinicians to assure safe transitions and reduce readmissions.

The role blends clinical insight with care coordination, requiring strong communication and organization. Field-based with emphasis on rapid follow-up and patient-centered care, supporting agency growth.

Qualifications

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

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.

Skills

RN/LVN/LPN/PT license

Clinical experience

Care coordination

EMR proficiency

Tools

EMR systems

HCHB EMR

Job description

VitalCaring Group is seeking a Care Transition Navigator (CTN) for field-based hospital-to-home coordination. You will work with hospital teams, patients, and clinicians to assure safe transitions and reduce readmissions.

The role blends clinical insight with care coordination, requiring strong communication and organization. Field-based with emphasis on rapid follow-up and patient-centered care, supporting agency growth.