Hospital-to-Home Care Transition Navigator

VitalCaring Group; Ocala (FL); On-site; USD 60,000 - 90,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

401(k) with company match

Flexible spending accounts (FSA)

Job summary

VitalCaring Group is seeking a Care Transition Navigator (CTN) to coordinate safe transitions from hospital to home health. This field-based role partners with hospital teams, physicians and families to reduce readmissions and improve outcomes.

The position requires an active RN/LVN/LPN or PT license and at least two years of clinical experience, with EMR familiarity and strong communication skills. A logistics mindset and reliability are essential for success in this high-impact 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.

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/LVN/LPN or PT license

Clinical experience

EMR proficiency

Tools

EMR systems (HCHB)

Job description

VitalCaring Group is seeking a Care Transition Navigator (CTN) to coordinate safe transitions from hospital to home health. This field-based role partners with hospital teams, physicians and families to reduce readmissions and improve outcomes.

The position requires an active RN/LVN/LPN or PT license and at least two years of clinical experience, with EMR familiarity and strong communication skills. A logistics mindset and reliability are essential for success in this high-impact role.