Field-Based Care Transition Navigator - Healthcare Impact

VitalCaring Group; Port Charlotte (FL); On-site; USD 60,000 - 85,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Virtual care

Mental health support

FSA

HSA

Life insurance

401(k) match

Referral program

Legal services

Identity protection

Work-Life balance

Paid time off

Education reimbursement

Job summary

VitalCaring Group is seeking a Care Transition Navigator (CTN) – Home Health to coordinate hospital-to-home transitions. This field-based role works with hospital teams, patients, and families to ensure safe discharges and timely admissions.

Responsibilities include bedside assessments, discharge planning, and collaboration with case managers and physicians to support agency growth. RN/LVN/PT license holders with 2+ years of experience are invited to apply.

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 patients, families, and clinicians.
• High level of organization to manage multiple patients and priorities.
• Proficiency with EMR systems and basic computer applications.
• Valid driver’s license and reliable transportation.

Responsibilities

• Serve as primary liaison between hospital teams, patients, and VitalCaring clinicians for hospital-to-home transitions.
• Conduct bedside assessments to identify clinical needs, risks, and discharge barriers.
• Develop and execute safe, patient-centered transition plans with case managers and physicians.
• Drive timely admissions by coordinating referrals and handoffs to home health services.
• Build strong relationships with hospital partners through consistent communication and follow-through.
• Complete post-discharge follow-up within 48 hours and coordinate primary care.
• Collaborate with internal teams to improve outcomes and reduce readmissions.

Skills

RN license

LVN/LPN license

PT license

Clinical experience

Care coordination

EMR proficiency

Driver's license

Job description

VitalCaring Group is seeking a Care Transition Navigator (CTN) – Home Health to coordinate hospital-to-home transitions. This field-based role works with hospital teams, patients, and families to ensure safe discharges and timely admissions.

Responsibilities include bedside assessments, discharge planning, and collaboration with case managers and physicians to support agency growth. RN/LVN/PT license holders with 2+ years of experience are invited to apply.