Hospital-to-Home Care Transition Navigator

VitalCaring Group; Springfield (MO); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Medical, Dental, Vision coverage

Virtual care and mental health support

401(k) with company match

Employee referral program

CE reimbursement

Job summary

VitalCaring Group seeks a Care Transition Navigator to coordinate safe hospital-to-home transitions. You’ll work with hospital teams, case managers, patients, and families to reduce readmissions and improve outcomes.

The role blends clinical insight with care coordination and referral management, supporting both patient success and agency growth. Travel to assigned hospitals is required.

Qualifications

• Active RN/LVN/LPN or PT license in the state of employment (or compact eligibility).
• Minimum of two (2) 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.
• 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 health.
• 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

Communication skills

Organization

EMR proficiency

Relationship building

Education

Active RN/LVN/LPN or PT license in state

Compact eligibility (if applicable)

Tools

EMR systems (HCHB)

Job description

VitalCaring Group seeks a Care Transition Navigator to coordinate safe hospital-to-home transitions. You’ll work with hospital teams, case managers, patients, and families to reduce readmissions and improve outcomes.

The role blends clinical insight with care coordination and referral management, supporting both patient success and agency growth. Travel to assigned hospitals is required.