Hospital-to-Home Care Transition Navigator

Vitalcaring-Group; Independence (MO); 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

401(k) with company match

Generous paid time off

Tuition and continuing education reimb

Employee referral program

Prepaid legal services

Identity theft protection

Job summary

VitalCaring is seeking a Care Transition Navigator (CTN) to ensure safe transitions from hospital to home health care. This field-based role collaborates with case managers, physicians, patients, and families to coordinate care, reduce readmissions, and improve outcomes.

You will conduct bedside assessments, develop transition plans with clinicians, and drive timely admissions into home health services. Strong communication and organization are essential to succeed in this role.

Qualifications

• Active RN, LVN/LPN, or PT license in the state of employment (or compact eligibility).
• Minimum of two 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.

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

Job description

VitalCaring is seeking a Care Transition Navigator (CTN) to ensure safe transitions from hospital to home health care. This field-based role collaborates with case managers, physicians, patients, and families to coordinate care, reduce readmissions, and improve outcomes.

You will conduct bedside assessments, develop transition plans with clinicians, and drive timely admissions into home health services. Strong communication and organization are essential to succeed in this role.