Impactful Care Transition Navigator – Home Health Field

VitalCaring Group; Venice (FL); On-site; USD 60,000 - 80,000; Full time

Benefits offered by this job

Medical, dental, vision coverage

401(k) with company match

Generous paid time off

Tuition and CE reimbursement

Employee referral program

FSA / HSA options

Job summary

VitalCaring Group is seeking a Care Transition Navigator (CTN) to manage hospital-to-home transitions. This field-based role works with hospital teams, case managers, physicians, patients and families to coordinate care, reduce readmissions, and improve outcomes for home health services.

The role emphasizes relationship-building, timely referrals, and adherence to discharge plans in a fast-paced environment. A current state license and 2+ years clinical experience are required.

Qualifications

• Active clinical license in the state of employment or compact eligibility.
• Minimum of two years of clinical experience; home health or post-acute preferred.
• Experience in healthcare coordination, case management, or hospital-based roles.
• Knowledge of patient care transitions, discharge planning, or post-acute services.
• Proven ability to build relationships with healthcare providers and interdisciplinary teams.
• Excellent communication skills and strong organizational abilities.

Responsibilities

• Serve as liaison between hospital teams, patients, and VitalCaring clinicians for smooth transitions.
• Conduct bedside assessments to identify clinical needs and discharge barriers.
• Collaborate with case managers and physicians on transition plans.
• Coordinate referrals to drive timely admissions into home health services.
• Build strong relationships with hospital partners through clear communication.
• Complete post-discharge follow-up within 48 hours and ensure care coordination.

Skills

Active RN/LVN/LPN/PT license

Clinical experience

EMR proficiency

Strong communication

Organization & time management

Tools

EMR systems

HCHB EMR

Job description

VitalCaring Group is seeking a Care Transition Navigator (CTN) to manage hospital-to-home transitions. This field-based role works with hospital teams, case managers, physicians, patients and families to coordinate care, reduce readmissions, and improve outcomes for home health services.

The role emphasizes relationship-building, timely referrals, and adherence to discharge plans in a fast-paced environment. A current state license and 2+ years clinical experience are required.