Hospital-to-Home Care Transition Navigator

VitalCaring Group; Independence (MO); On-site; USD 70,000 - 100,000; Full time

Benefits offered by this job

Medical, dental, vision coverage

401(k) with company match

Tuition and continuing education

Job summary

VitalCaring Group is seeking a Care Transition Navigator (CTN) to coordinate safe hospital-to-home transitions within hospital systems. You will partner with case managers, physicians, patients, and families to reduce readmissions, support care plans, and drive timely admissions to home health services.

This field-based role emphasizes relationship-building, clinical insight, and proactive follow-through in a fast-paced healthcare environment.

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, or hospital-based roles
• Strong understanding of patient care transitions, discharge planning, or post-acute services
• Excellent communication skills with patients, families, and clinicians
• Organizational skills with ability to manage multiple patients and priorities
• Proficiency with EMR systems and basic computer applications
• Valid driver’s license and reliable transportation

Responsibilities

• Serve as liaison between hospital teams, patients, and VitalCaring clinicians to ensure seamless transitions
• Conduct bedside assessments to identify clinical needs and barriers to discharge
• Partner with case managers and physicians to develop safe transition plans
• Drive admissions by coordinating referrals and ensuring smooth HHC handoffs
• Build strong relationships with hospital partners through consistent communication
• Complete post-discharge follow-up within 48 hours and coordinate primary care
• Collaborate with internal teams to improve outcomes and reduce readmissions

Skills

Communication skills

Relationship-building

Time management

Multitasking

Interdisciplinary collaboration

Education

RN/LVN/LPN/PT license in state

Tools

EMR systems

Homecare Homebase (HCHB)

Job description

VitalCaring Group is seeking a Care Transition Navigator (CTN) to coordinate safe hospital-to-home transitions within hospital systems. You will partner with case managers, physicians, patients, and families to reduce readmissions, support care plans, and drive timely admissions to home health services.

This field-based role emphasizes relationship-building, clinical insight, and proactive follow-through in a fast-paced healthcare environment.