Hospital-to-Home Care Navigator

VitalCaring Group; Georgetown (TX); On-site; USD 60,000 - 90,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

401(k) with company match

Education reimbursement

Paid time off

Job summary

VitalCaring welcomes a Care Transition Navigator (CTN) to coordinate patient transitions from hospital to home health. This field-based role collaborates with hospital teams, physicians, patients and families to ensure safe admissions, reduce readmissions, and improve outcomes.

The ideal candidate holds an active RN/LVN/LPT license in the state of employment, has 2+ years of clinical experience, and demonstrates EMR proficiency. Strong communication and travel to hospitals are essential.

Qualifications

• Active RN, LVN/LPN, or PT license in the state of employment.
• Minimum 2 years of clinical experience; home health or post-acute preferred.
• Experience in healthcare coordination or case management.
• Strong understanding of patient care transitions or discharge planning.
• Excellent communication and organizational skills.
• Valid driver’s license and reliable transportation.

Responsibilities

• Serve as liaison between hospital teams, patients, and VitalCaring clinicians for smooth transitions.
• Perform bedside assessments to identify needs, risks, and barriers to discharge.
• Collaborate with case managers and physicians to develop safe transition plans.
• Coordinate referrals to drive timely admissions into home health services.
• Build relationships with hospital partners through consistent communication.
• Complete post-discharge follow-up within 48 hours and coordinate primary care.
• Support internal teams in initiatives to improve outcomes and reduce readmissions.

Skills

RN license

LVN/LPN license

PT license

Discharge planning

EMR proficiency

Communication skills

Tools

EMR systems (HCHB)

Job description

VitalCaring welcomes a Care Transition Navigator (CTN) to coordinate patient transitions from hospital to home health. This field-based role collaborates with hospital teams, physicians, patients and families to ensure safe admissions, reduce readmissions, and improve outcomes.

The ideal candidate holds an active RN/LVN/LPT license in the state of employment, has 2+ years of clinical experience, and demonstrates EMR proficiency. Strong communication and travel to hospitals are essential.