Care Transition Navigator

Join VitalCaring as a Care Transition Navigator – Home Health in a field-based, hospital-focused role supporting patient transition and care coordination.

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 to ensure 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 that invests in your success.
• Grow Your Career – Advanced training, mentorship, and career development opportunities.
• Competitive Pay & Benefits – Comprehensive compensation and recognition programs.

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 relationship-driven role blending clinical insight, care coordination, and referral management to support 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 patient-centered transition plans.
• Coordinate referrals and admissions into home health services.
• Build relationships with hospital partners through communication and follow-through.
• Complete post-discharge follow-up within 48 hours and ensure 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.
• Minimum two years of clinical experience.
• Experience in healthcare coordination, case management, clinical care, or hospital-based roles.
• Understanding of patient care transitions, discharge planning, or post-acute services.
• Ability to build relationships with healthcare providers and interdisciplinary teams.
• Excellent communication skills.
• Strong organizational and multitasking abilities.
• Proficiency with EMR systems and 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 hospitals and healthcare facilities.
• Patient-facing position requiring interpersonal and clinical communication skills.
• Fast-paced environment requiring adaptability and critical thinking.
• Performance expectations tied to patient outcomes and care transitions.
• Strong time management required for 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 based on job-related qualifications, skills, and business needs.