Hospital-to-Home Care Transition Navigator

VitalCaring Group; San Antonio (TX); On-site; USD 68,000 - 95,000; Full time

Benefits offered by this job

Medical, Dental, and Vision coverage

401(k) with company match

FSA & HSA

Life insurance

Employee referral program

Identity theft protection

Tuition reimbursement

Work-life balance

Job summary

VitalCaring Group is seeking a Care Transition Navigator to ensure safe transitions from hospital to home health care. You will work within hospital systems, coordinating with case managers, physicians, patients, and families to reduce readmissions and improve outcomes.

The role blends clinical insight with care coordination and referral management to support patient success and agency growth. Field-based with hospital partnerships.

Qualifications

• Active RN, LVN/LPN, or PT license in Texas
• Minimum of two years 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

Skills

RN/LVN/LPT license

Clinical experience

Healthcare coordination

Discharge planning

Communication skills

Time management

EMR proficiency

Tools

EMR systems

Basic computer skills

Job description

VitalCaring Group is seeking a Care Transition Navigator to ensure safe transitions from hospital to home health care. You will work within hospital systems, coordinating with case managers, physicians, patients, and families to reduce readmissions and improve outcomes.

The role blends clinical insight with care coordination and referral management to support patient success and agency growth. Field-based with hospital partnerships.