Hospital-to-Home Care Transition Navigator

Vitalcaring-Group; McKinney (TX); On-site; USD 34,000 - 55,000; Part time

Benefits offered by this job

6 PTO days per year

Company holidays are yours

401(k) eligibility

Job summary

VitalCaring is seeking a Care Transition Navigator to coordinate hospital-to-home transitions for patients in a field-based role serving Texas facilities. The position emphasizes clinical insight, care coordination, and efficient referrals to reduce readmissions and improve outcomes.

This part-time, weekend-focused role requires an active nursing license, strong communication, and the ability to manage multiple patients, with dedicated time in hospital partnerships and patient follow-up.

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.

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.

Skills

RN license

Clinical experience

Healthcare coordination

Discharge planning

Communication skills

EMR proficiency

Driver’s license

Tools

EMR systems

Job description

VitalCaring is seeking a Care Transition Navigator to coordinate hospital-to-home transitions for patients in a field-based role serving Texas facilities. The position emphasizes clinical insight, care coordination, and efficient referrals to reduce readmissions and improve outcomes.

This part-time, weekend-focused role requires an active nursing license, strong communication, and the ability to manage multiple patients, with dedicated time in hospital partnerships and patient follow-up.