Hospital-to-Home Care Transition Navigator

Vitalcaring-Group; San Antonio (TX); On-site; USD 24,000 - 36,000; Part time

Benefits offered by this job

6 PTO days per year

Company holidays are yours

401(k) eligibility

Job summary

VitalCaring is hiring a Care Transition Navigator to coordinate hospital-to-home transitions, working field-based across assigned hospitals, focusing on safe discharges and reducing readmissions. This 16-hour-per-week weekend position requires an active RN, LVN/LPN, or PT license in the state, with 2+ years clinical experience and experience in care coordination.

You will partner with case managers and physicians, manage referrals, and ensure timely post-discharge follow-up while balancing

Qualifications

• Active RN, LVN/LPN, or PT license in the state of employment.
• Minimum of two (2) years of clinical experience; home health or post-acute care preferred.
• Experience in healthcare coordination, case management, 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 liaison between hospital teams, patients, and VitalCaring clinicians for hospital-to-home transitions.
• Conduct bedside assessments to identify clinical needs and barriers to discharge.
• Partner with case managers and physicians to develop safe, patient-centered transition plans.
• Drive timely admissions by coordinating referrals and handoffs to home health services.
• Build strong relationships with hospital partners through consistent communication.
• Complete post-discharge follow-up within 48 hours and coordinate follow-up with primary care.
• Collaborate with internal teams to improve outcomes and reduce readmissions.

Skills

Care coordination

Discharge planning

Patient communication

Relationship building

Multitasking

Tools

EMR systems

HCHB (Homecare Homebase)

Job description

VitalCaring is hiring a Care Transition Navigator to coordinate hospital-to-home transitions, working field-based across assigned hospitals, focusing on safe discharges and reducing readmissions. This 16-hour-per-week weekend position requires an active RN, LVN/LPN, or PT license in the state, with 2+ years clinical experience and experience in care coordination.

You will partner with case managers and physicians, manage referrals, and ensure timely post-discharge follow-up while balancing