Hospital-to-Home Care Navigator: Impactful Transitions

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

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Mental health support

401(k) matching

Employee referral program

Legal services

Identity protection

Job summary

VitalCaring Group is seeking a Care Transition Navigator (CTN) to ensure safe hospital-to-home transitions. This field-based role works with hospital teams, physicians, and families to coordinate care, reduce readmissions, and improve patient outcomes.

The position blends clinical insight with care coordination and requires an RN/LVN/LPN or PT license, 2+ years of clinical experience, and EMR proficiency. Travel to partner hospitals will be involved; benefits are provided.

Qualifications

• Active RN/LVN/LPN or PT license in the state of employment.
• Minimum 2 years clinical experience; home health or post-acute preferred.
• Experience in healthcare coordination, case management, or hospital-based roles.
• Strong understanding of patient care transitions and discharge planning.
• Ability to build relationships with healthcare providers and teams.
• Excellent communication with patients, families, and clinicians.
• Good organizational skills with multitasking capability.
• Proficiency with EMR systems and basic computer applications.

Responsibilities

• Serve as liaison between hospital teams, patients, and VitalCaring clinicians for smooth transitions.
• Conduct bedside assessments to identify clinical needs and barriers to discharge.
• Collaborate with case managers and physicians on transition plans.
• Drive timely admissions by coordinating referrals and handoffs to home health.
• Build strong relationships with hospital partners through communication.
• Perform post-discharge follow-up within 48 hours and coordinate primary care.
• Collaborate with internal teams to improve outcomes and reduce readmissions.

Skills

Nursing license

Clinical experience

Healthcare coordination

Discharge planning

EMR proficiency

Driver’s license

Education

Nursing/therapy license

Tools

EMR systems

HCHB EMR

Job description

VitalCaring Group is seeking a Care Transition Navigator (CTN) to ensure safe hospital-to-home transitions. This field-based role works with hospital teams, physicians, and families to coordinate care, reduce readmissions, and improve patient outcomes.

The position blends clinical insight with care coordination and requires an RN/LVN/LPN or PT license, 2+ years of clinical experience, and EMR proficiency. Travel to partner hospitals will be involved; benefits are provided.