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 and represents innovative solutions that make a difference for patients and families.
• 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 – Access advanced training, mentorship, and career development opportunities.
• Competitive Pay & Benefits – Receive a compensation package designed to reflect your value and support your well-being.

Role Overview

The Care Transition Navigator (CTN) – Home Health is a field-based, hospital-focused role centered on patient transition and care coordination. The position ensures safe, seamless transitions from the hospital to home health care by partnering with case managers, physicians, patients, and families to coordinate care, reduce readmissions, and improve outcomes.

This is a high-impact, relationship-driven role blending 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 discharge barriers.
• Partner with case managers and physicians to develop and execute patient-centered transition plans.
• Coordinate referrals and ensure smooth handoffs into home health services.
• Build and maintain trusted relationships with hospital partners.
• 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 and organizational skills.
• 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.
• Hospital system experience in case management or discharge planning.
• 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 environment requiring strong clinical communication.
• Fast-paced setting requiring adaptability, critical thinking, and proactive follow-through.
• Performance expectations tied to patient outcomes and successful care transitions.
• Strong time management balancing coordination, patient interaction, and documentation.

Benefits

• Health & Wellness: Medical, Dental, Vision, Pharmacy benefits, Virtual care, FSA, 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 race, color, religion, sex, gender identity or expression, sexual orientation, national origin, age, disability, veteran status, or any other protected characteristic. Candidates are evaluated based on job-related qualifications, skills, and business needs.