Care Transition Navigator

Join VitalCaring – Where Your Passion Changes Lives!

Who We Are

Founded in 2021, VitalCaring has grown into a leading provider of home health and hospice services, with over 100 locations across the country. We are committed to fostering a culture of support, growth, and excellence for our team that is the backbone of how we ensure we deliver exceptional patient care.

What Sets Us Apart?

• Drive Innovation. Deliver Impact - Join a mission-driven team where your work directly contributes to advancing patient care.
• Make a Meaningful Impact – Help patients and families navigate their healthcare journey with compassion and dignity.
• Thrive in a Supportive Team – Work with a team who genuinely care and invest in your success.
• Grow Your Career – Take advantage of advanced training, mentorship, and career development opportunities.
• Competitive Pay & Benefits – A compensation package designed to reflect your value and support your well-being.

Care Transition Navigator (CTN) – Home Health

Field-Based | Hospital-Focused | Patient Transition & Care Coordination

Role Overview

The Care Transition Navigator plays a critical role in ensuring safe, seamless transitions from the hospital to home health care. This position works directly within assigned hospital systems, partnering with case managers, physicians, patients, and families to coordinate care, reduce readmissions, and improve patient outcomes.

This is a high-impact, relationship-driven role that blends clinical insight, care coordination, and referral management to support both patient success and agency growth.

Key Responsibilities

• Serve as the primary liaison between hospital teams, patients, and 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 to improve outcomes and reduce readmissions

Required Qualifications

• Active RN, LVN/LPN, or PT license in the state of employment (or compact eligibility, if applicable)
• Minimum of two (2) years of clinical experience
• Experience in healthcare coordination, case management, clinical care, or hospital-based roles
• Strong understanding of patient care transitions, discharge planning, or post-acute services
• Demonstrated ability to build relationships with healthcare providers and interdisciplinary teams
• Excellent communication skills
• High level of organization and ability to manage multiple priorities
• Proficiency with EMR systems and basic computer applications
• Valid driver's license and reliable transportation

Preferred Qualifications

• Experience in home health, hospice, or post-acute care
• Background working within hospital systems
• Knowledge of CMS guidelines and readmission reduction strategies
• Familiarity with Homecare Homebase (HCHB) or similar EMR systems

Work Environment & Expectations

• Field-based role with regular presence in assigned hospitals and healthcare facilities
• High-touch, patient-facing position
• Fast-paced environment requiring adaptability and critical thinking
• Performance expectations tied to patient outcomes and successful care transitions
• Strong time management balancing coordination, interaction, and documentation

Benefits

Health & Wellness

• Medical, Dental, and Vision coverage
• Pharmacy benefits
• Virtual care and mental health support
• Flexible Spending Accounts (FSA) and Health Savings Account (HSA)
• Supplemental health and life insurance

Financial & Protection

• 401(k) with company match
• Employee referral program
• Prepaid legal services
• Identity theft protection

Work-Life Balance & Perks

• Generous paid time off
• Pet insurance
• Tuition and continuing education reimbursement

All employment decisions are made without regard to protected characteristics. Candidates are evaluated based on job-related qualifications, skills, and business needs.