Field-Based Care Transition Navigator — Home Health

VitalCaring Group; Moore (OK); On-site; USD 55,000 - 85,000; Full time

Benefits offered by this job

Medical, Dental, and Vision coverage

Virtual care and mental health support

Flexible Spending Accounts (FSA) and H

Job summary

VitalCaring Group in Moore, OK is seeking a Care Transition Navigator (CTN) to coordinate hospital-to-home transitions for patients receiving home health care. This field-based role partners with hospital teams, case managers, physicians, patients and families to ensure safe, seamless transitions and high-quality care.

As a key liaison, you will identify needs, reduce readmissions, and support care coordination and referrals.

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, 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 with the ability to manage multiple patients
• Proficiency with EMR systems and basic computer applications
• Valid driver’s license and reliable transportation

Responsibilities

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

Skills

Clinical coordination

Discharge planning

Patient communication

Care coordination

Time management

Education

Active RN, LVN/LPN, or PT license (state)

Tools

EMR systems

Homecare Homebase (HCHB)

Basic computer applications

Job description

VitalCaring Group in Moore, OK is seeking a Care Transition Navigator (CTN) to coordinate hospital-to-home transitions for patients receiving home health care. This field-based role partners with hospital teams, case managers, physicians, patients and families to ensure safe, seamless transitions and high-quality care.

As a key liaison, you will identify needs, reduce readmissions, and support care coordination and referrals.