Strategic Hospital-to-Home Care Navigator

VitalCaring Group; Noble (OK); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Medical, Dental, Vision coverage

401(k) with company match

Flexible Spending Accounts (FSA) / HSA

Employee referral program

Job summary

VitalCaring Group is seeking a Field-Based Care Transition Navigator to join our hospital-focused home health team. You will coordinate transitions from hospital to home health, partner with case managers, physicians, patients and families, and help reduce readmissions while improving patient outcomes.

This high-impact role requires clinical insight, strong communication, and the ability to manage multiple referrals and priorities.

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 care preferred.
• Experience in healthcare coordination, case management, or hospital-based roles.
• Strong ability to build relationships with providers and families.
• Proficient with EMR systems and basic computer applications.

Responsibilities

• Serve as primary liaison between hospital teams, patients, and VitalCaring clinicians for smooth transitions.
• Conduct bedside assessments to identify clinical needs and barriers to discharge.
• Develop and execute safe, patient-centered transition plans with case managers and physicians.
• Drive timely admissions by coordinating referrals and handoffs to home health services.
• Build trusted relationships with hospital partners through consistent communication.
• Perform post-discharge follow-up within 48 hours and coordinate primary care.
• Collaborate with internal teams to improve outcomes and reduce readmissions.

Skills

Active RN license

LVN/LPN license

PT license

Clinical experience

Care coordination

Discharge planning

Communication skills

Organization

EMR proficiency

Driver's license

Tools

Homecare Homebase (HCHB)

EMR systems

Job description

VitalCaring Group is seeking a Field-Based Care Transition Navigator to join our hospital-focused home health team. You will coordinate transitions from hospital to home health, partner with case managers, physicians, patients and families, and help reduce readmissions while improving patient outcomes.

This high-impact role requires clinical insight, strong communication, and the ability to manage multiple referrals and priorities.