Field-Based Care Transition Navigator — Home Health

VitalCaring Group; San Antonio (TX); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Medical, Dental, Vision

401(k) match

Paid time off

Flexible Spending Accounts

Education reimbursement

Job summary

VitalCaring Group is seeking a Care Transition Navigator (CTN) – Home Health, field-based and hospital-focused, to coordinate patient care transitions from hospital to home health services. You will work with case managers, physicians, patients, and families to reduce readmissions and improve outcomes.

This role blends clinical insight with care coordination and referrals to support patient success and agency growth.

Qualifications

• Active RN, LVN/LPN, or PT license in the state of employment.
• 2:
• 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 the ability to engage patients, families, and clinicians effectively.
• High level of organization with the ability to manage multiple patients and priorities simultaneously.
• Proficiency with EMR systems and basic computer applications.
• Valid driver’s license and reliable transportation.

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

Clinical coordination

Care transitions

Discharge planning

Strong communication

EMR proficiency

Time management

Education

RN/LVN/LPN/PT license

Tools

EMR systems

HCHB or similar EMR

Job description

VitalCaring Group is seeking a Care Transition Navigator (CTN) – Home Health, field-based and hospital-focused, to coordinate patient care transitions from hospital to home health services. You will work with case managers, physicians, patients, and families to reduce readmissions and improve outcomes.

This role blends clinical insight with care coordination and referrals to support patient success and agency growth.