Field-Based Care Transition Navigator - Home Health

VitalCaring Group; Purcell (OK); On-site; USD 70,000 - 95,000; Full time

Benefits offered by this job

Medical, Dental, and Vision coverage

401(k) with company match

Paid time off

Tuition reimbursement

Flexible Spending Accounts

Job summary

VitalCaring Group is seeking a field-based Sales Care Transition Navigator to coordinate hospital-to-home transitions for home health patients. You will work directly with hospital teams, physicians, patients, and families to ensure smooth care transitions and reduce readmissions.

The role blends clinical insight with care coordination, requiring strong communication and organizational skills to support patient success and agency growth.

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.

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.
• Collaborate with internal teams and support initiatives focused on improving outcomes and reducing readmissions.

Skills

Care coordination

Discharge planning

Patient communication

Relationship building

Hospital-to-home transitions

Tools

EMR systems

Job description

VitalCaring Group is seeking a field-based Sales Care Transition Navigator to coordinate hospital-to-home transitions for home health patients. You will work directly with hospital teams, physicians, patients, and families to ensure smooth care transitions and reduce readmissions.

The role blends clinical insight with care coordination, requiring strong communication and organizational skills to support patient success and agency growth.