Hospital-to-Home Care Transition Navigator

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

Benefits offered by this job

Medical, Dental, and Vision coverage

Virtual care and mental health support

FSA & HSA

Supplemental health and life insurance

401(k) with company match

Employee referral program

Prepaid legal services

Identity theft protection

Generous paid time off

Tuition and continuing education reimb

Reimbursement for continuing education

Job summary

VitalCaring Group is seeking a Care Transition Navigator (CTN) – Home Health to coordinate hospital-to-home transitions. You will work field-based within hospital systems, partnering with case managers, physicians, patients, and families to reduce readmissions and improve outcomes.

This high-impact role blends clinical insight with care coordination and referral management to support patient success and agency growth.

Qualifications

• Active RN, LVN/LPN, or PT license in the state of employment.
• Minimum of two years of clinical experience; home health or post-acute experience preferred.
• Experience in healthcare coordination, case management, or hospital-based roles.
• Excellent communication skills with the ability to engage patients, families, and clinicians effectively.
• Proficiency with EMR systems and driving responsibilities.

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 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

Home health

Discharge planning

Communication

EMR proficiency

Driver's license

Tools

EMR systems

Job description

Join VitalCaring – Where Your Passion Changes Lives!

Who We Are

Founded in 2021, VitalCaring has grown into a leading provider of home health and hospice services, with over 100 locations across the country. We are committed to fostering a culture of support, growth, and excellence for our team that is the backbone of how we ensure we deliver exceptional patient care.

What Sets Us Apart?

• Drive Innovation. Deliver Impact - Join a mission-driven team where your work directly contributes to advancing patient care. As a key player in a forward-thinking healthcare organization, you’ll represent innovative solutions that truly make a difference for patients and families - today and into the future
• Make a Meaningful Impact – Help patients and families navigate their healthcare journey with compassion and dignity.
• Thrive in a Supportive Team – Work with a team who genuinely care and invest in your success.
• Grow Your Career – Take advantage of advanced training, mentorship, and career development opportunities.
• Competitive Pay & Benefits – Be rewarded for your dedication and expertise with a compensationpackage that truly reflects your value. Our benefits are thoughtfully designed to support your well-being—offering the flexibility, security, and resources you need to thrive both at work and in life. Wecelebrate success at every level, with meaningful recognition for both individual contributions and teamachievements.

Care Transition Navigator (CTN) – Home Health

Field-Based | Hospital-Focused | Patient Transition & Care Coordination

Role Overview

The Care Transition Navigator plays a critical role in ensuring safe, seamless transitions from the hospital to home health care. This position works directly within assigned hospital systems, partnering with case managers, physicians, patients, and families to coordinate care, reduce readmissions, and improve patient outcomes.

This is a high-impact, relationship-driven role that blends clinical insight, care coordination, and referral management to support both patient success and agency growth.

Key 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

Required 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
• Excellent communication skills with the ability to engage patients, families, and clinicians effectively
• High level of organization with the ability to manage multiple patients and priorities simultaneously
• Proficiency with EMR systems and basic computer applications
• Valid driver’s license and reliable transportation

Preferred Qualifications

• Experience in home health, hospice, or post-acute care
• Background working within hospital systems (case management, discharge planning, or bedside coordination)
• Knowledge of CMS guidelines and readmission reduction strategies
• Familiarity with Homecare Homebase (HCHB) or similar EMR systems

Work Environment & Expectations

• Field-based role with regular presence in assigned hospitals and healthcare facilities
• High-touch, patient-facing position requiring strong interpersonal and clinical communication skills
• Fast-paced environment requiring adaptability, critical thinking, and proactive follow-through
• Performance expectations tied to both patient outcomes and successful care transitions/admissions
• Requires strong time management to balance hospital coordination, patient interaction, and documentation

Medical, Dental, and Vision coverage

Virtual care and mental health support

Flexible Spending Accounts (FSA) and Health Savings Account (HSA)

Supplemental health and life insurance

401(k) with company match

Employee referral program

Prepaid legal services

Identity theft protection

Work-Life Balance & Perks

Generous paid time off

Tuition and continuing education reimbursement

All employment decisions are made without regard to race, color, religion, sex, gender identity or expression, sexual orientation, national origin, age, disability, veteran status, or any other protected characteristic. Candidates are evaluated based on job-related qualifications, skills, and business needs.