Hospital-to-Home Transition Navigator

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

Benefits offered by this job

Medical, dental, vision coverage

401(k) with company match

Tuition reimbursement

Flexible spending accounts

Job summary

VitalCaring Group is seeking a Care Transition Navigator (CTN) to ensure safe hospital-to-home health transitions. The role works with hospital teams, case managers, physicians, patients, and families to coordinate care and reduce readmissions.

This field-based, patient-facing position blends clinical insight with care coordination and referral management to support patient success and agency growth. Applicants should have active licenses and a minimum of two years of clinical experience,

Qualifications

• Active RN, LVN/LPN, or PT license in the state of employment.
• 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.
• 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

Skills

Care coordination

Discharge planning

EMR proficiency

Strong communication

Time management

Education

RN license

LVN/LPN license

PT license

Job description

VitalCaring Group is seeking a Care Transition Navigator (CTN) to ensure safe hospital-to-home health transitions. The role works with hospital teams, case managers, physicians, patients, and families to coordinate care and reduce readmissions.

This field-based, patient-facing position blends clinical insight with care coordination and referral management to support patient success and agency growth. Applicants should have active licenses and a minimum of two years of clinical experience,