Care Transition Navigator: Transform Hospital-to-Home Care

VitalCaring Group; Cibolo (TX); On-site; USD 55,000 - 75,000; Full time

Benefits offered by this job

Medical, Dental, and Vision coverage

401(k) with company match

Flexible Spending Accounts (FSA) and H

Employee referral program

Tuition reimbursement

Job summary

VitalCaring Group in Texas is seeking a Care Transition Navigator (CTN) to ensure safe transitions from hospital to home health care. You will work directly with hospital systems, case managers, physicians, patients, and families to coordinate care, reduce readmissions, and improve outcomes.

This field-based role blends clinical insight with care coordination and referral management, requiring strong communication, organization, and the ability to manage multiple patients while navigating busy

Qualifications

• Active RN, LVN/LPN, or PT license in the state of employment.
• Minimum of two years of 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, discharge planning, or post-acute services.
• Demonstrated ability to build relationships with healthcare providers and interdisciplinary teams.
• Excellent communication skills with patients, families, and clinicians.

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 relationships with hospital partners through consistent communication and follow-through.
• Complete post-discharge follow-up within 48 hours.

Skills

RN License

LVN/LPN License

PT License

EMR Systems

Homecare Homebase (HCHB)

Basic Computer Skills

Tools

EMR Systems

Homecare Homebase (HCHB)

Job description

VitalCaring Group in Texas is seeking a Care Transition Navigator (CTN) to ensure safe transitions from hospital to home health care. You will work directly with hospital systems, case managers, physicians, patients, and families to coordinate care, reduce readmissions, and improve outcomes.

This field-based role blends clinical insight with care coordination and referral management, requiring strong communication, organization, and the ability to manage multiple patients while navigating busy