RN-Led Hospital-to-Home Discharge Navigator

VitalCaring Group; The Villages (FL); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Virtual care and mental health support

Health Savings Account (HSA)

Flexible Spending Accounts (FSA)

401(k) with company match

Employee referral program

Prepaid legal services

Identity theft protection

Generous paid time off

Tuition and continuing education Reimb

Job summary

VitalCaring Group is seeking a Care Transition Navigator (CTN) to coordinate hospital-to-home transitions for home health patients. The role blends clinical insight with care coordination and referral management to support patient success and agency growth.

You will work within hospital systems, partner with case managers and physicians, and focus on reducing readmissions while ensuring smooth handoffs and timely follow-up.

Qualifications

• Active RN, LVN/LPN, or PT license in the state of employment (or compact eligibility).
• Minimum of two years of clinical experience; home health or post-acute experience preferred.
• Experience in healthcare coordination, case management, or hospital-based roles.
• Strong understanding of patient care transitions and discharge planning.
• Excellent communication with patients, families, and clinicians; well organized and proactive.
• Proficiency with EMR systems and basic computer applications; valid driver’s license.

Responsibilities

• Serve as 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 discharge barriers.
• Partner with case managers and physicians to develop safe, patient-centered transition plans.
• Drive timely admissions by coordinating referrals and handoffs into home health services.
• Build trusted relationships with hospital partners through consistent communication and follow-through.
• Complete post-discharge follow-up within 48 hours and coordinate primary care when needed.

Skills

Communication skills

Organization

Interpersonal skills

Time management

Education

RN, LVN/LPN, or PT license in state of employment

Tools

EMR systems

Homecare Homebase (HCHB)

Job description

VitalCaring Group is seeking a Care Transition Navigator (CTN) to coordinate hospital-to-home transitions for home health patients. The role blends clinical insight with care coordination and referral management to support patient success and agency growth.

You will work within hospital systems, partner with case managers and physicians, and focus on reducing readmissions while ensuring smooth handoffs and timely follow-up.