Impactful Care Transition Navigator - Home Health

VitalCaring Group; Sulphur (LA); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Medical coverage

Dental & Vision

Virtual care

FSA/HSA

Life insurance

401(k) match

Referral program

Prepaid legal

ID theft protection

Paid time off

Education reimbursement

Job summary

VitalCaring is seeking a Care Transition Navigator to bridge hospital discharge and home health coordination, working field-based with hospitals to reduce readmissions and ensure safe transitions.

Requires active RN/LVN/LPT/PT license, 2+ years clinical experience, EMR proficiency, strong communication, and a valid driver’s license; will collaborate with case managers and physicians to plan patient-centered transition plans and coordinate referrals.

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, or hospital-based roles.
• Knowledge 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

Active RN/LVN/LPT license

Clinical experience 2+ years

Communication skills

Organization & multitasking

EMR proficiency

Driver’s license

Tools

EMR systems

HCHB EMR

Job description

VitalCaring is seeking a Care Transition Navigator to bridge hospital discharge and home health coordination, working field-based with hospitals to reduce readmissions and ensure safe transitions.

Requires active RN/LVN/LPT/PT license, 2+ years clinical experience, EMR proficiency, strong communication, and a valid driver’s license; will collaborate with case managers and physicians to plan patient-centered transition plans and coordinate referrals.