Hospital-to-Home Care Navigator

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

Benefits offered by this job

Medical, Dental, Vision coverage

401(k) with company match

Tuition reimbursement

Employee referral program

Job summary

VitalCaring Group is seeking a Care Transition Navigator (CTN) – Home Health. This field-based role works within hospital systems, coordinating with case managers, physicians, patients, and families to ensure safe transitions from hospital to home health care and to reduce readmissions.

The CTN blends clinical insight with care coordination to support patient success and agency growth, requiring a proactive, relationship-driven approach.

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.

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

Active RN/LVN/PT license

Clinical experience

EMR systems

Tools

EMR systems

Job description

VitalCaring Group is seeking a Care Transition Navigator (CTN) – Home Health. This field-based role works within hospital systems, coordinating with case managers, physicians, patients, and families to ensure safe transitions from hospital to home health care and to reduce readmissions.

The CTN blends clinical insight with care coordination to support patient success and agency growth, requiring a proactive, relationship-driven approach.