Hospital-to-Home Care Navigator

VitalCaring Group; Cedar Park (TX); On-site; USD 65,000 - 95,000; Full time

Benefits offered by this job

Medical, Dental, Vision coverage

401(k) with company match

Generous paid time off

Job summary

VitalCaring Group is seeking a Care Transition Navigator (CTN) for field-based, hospital-focused patient transitions and care coordination. The role partners with hospital teams, physicians, patients, and families to ensure safe discharge and smooth handoffs to home health services.

This high-impact position blends clinical insight with coordination and referral management to support patient outcomes and agency growth. Requires active clinical license and strong communication.

Qualifications

• Active RN, LVN/LPN, or PT license in the state of employment (or compact eligibility)
• Excellent communication skills with patients, families, and clinicians
• Strong organization and ability to manage multiple patients and priorities
• Experience in healthcare coordination, case management or discharge planning a plus
• Proficiency with EMR systems and basic computer applications

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 and barriers to discharge
• Partner with case managers and physicians to develop safe, patient-centered transition plans
• Drive timely admissions by coordinating referrals and handoffs to home health services
• Build trusted 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

Communication skills

Interpersonal skills

Time management

Clinical coordination

Education

RN/LVN/LPN/PT license

Tools

EMR systems

Homecare Homebase (HCHB)

Job description

VitalCaring Group is seeking a Care Transition Navigator (CTN) for field-based, hospital-focused patient transitions and care coordination. The role partners with hospital teams, physicians, patients, and families to ensure safe discharge and smooth handoffs to home health services.

This high-impact position blends clinical insight with coordination and referral management to support patient outcomes and agency growth. Requires active clinical license and strong communication.