Hospital-to-Home Care Navigator

VitalCaring Group; Boerne (TX); On-site; USD 70,000 - 100,000; Full time

Benefits offered by this job

Medical, Dental, and Vision coverage

Virtual care and mental health support

FSAs/HSA

Life insurance

401(k) with company match

Employee referral program

Tuition reimbursement

Continuing education reimbursement

Paid time off

Identity theft protection

Prepaid legal services

Job summary

VitalCaring Group is seeking a Care Transition Navigator (CTN) – Home Health to join our hospital-centric care coordination team. This field-based role partners with hospital case managers, physicians, patients and families to coordinate transitions from hospital to home health and reduce readmissions.

The CTN role blends clinical insight with referral management; you will ensure timely admissions, perform bedside assessments, and build strong relationships with hospital partners to support

Qualifications

• Active RN, LVN/LPN, or PT license in the state of employment (or compact eligibility).
• 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 ability to manage multiple patients and priorities.
• Valid driver’s license and reliable transportation.

Responsibilities

• Serve as liaison between hospital teams, patients, and VitalCaring clinicians to ensure seamless hospital-to-home transitions.
• Conduct bedside assessments to identify clinical needs, risk factors, 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 into home health services.
• Build strong 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 to improve outcomes and reduce readmissions.

Skills

RN license

LVN/LPN license

PT license

Driver's license

EMR systems

Tools

EMR systems

Basic computer apps

Job description

VitalCaring Group is seeking a Care Transition Navigator (CTN) – Home Health to join our hospital-centric care coordination team. This field-based role partners with hospital case managers, physicians, patients and families to coordinate transitions from hospital to home health and reduce readmissions.

The CTN role blends clinical insight with referral management; you will ensure timely admissions, perform bedside assessments, and build strong relationships with hospital partners to support