Hospital-to-Home Care Transition Navigator

VitalCaring Group; Fairview (TX); On-site; USD 60,000 - 95,000; Full time

Benefits offered by this job

Medical, Dental, and Vision coverage

401(k) with company match

FSA/HSA, flexible benefits

Paid time off

Job summary

VitalCaring is seeking a Care Transition Navigator (CTN) to coordinate safe hospital-to-home transitions and post-discharge care. You will work with hospital teams, physicians, and patients to reduce readmissions and improve outcomes.

This field-based role blends clinical insight with care coordination and referral management to grow agency impact while delivering compassionate patient care.

Qualifications

• Current licensure as RN, LVN/LPN or PT 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.

Responsibilities

• Serve as liaison between hospital teams, patients, and VitalCaring clinicians to ensure smooth transitions.
• 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 smooth handoffs to home health services.
• Build strong relationships with hospital partners through clear communication and follow-through.
• Complete post-discharge follow-up within 48 hours and coordinate with primary care.
• Collaborate with internal teams to improve outcomes and reduce readmissions.

Skills

Communication skills

Time management

Interdisciplinary collaboration

EMR proficiency

Relationship building

Education

Active RN/LVN/PT license (state)

Tools

Homecare Homebase (HCHB)

General EMR/IT systems

Job description

VitalCaring is seeking a Care Transition Navigator (CTN) to coordinate safe hospital-to-home transitions and post-discharge care. You will work with hospital teams, physicians, and patients to reduce readmissions and improve outcomes.

This field-based role blends clinical insight with care coordination and referral management to grow agency impact while delivering compassionate patient care.