Care Transition Navigator

VitalCaring Group•Springfield, MO

1d•Onsite

About The Position

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.

Requirements

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; home health or post-acute experience preferred
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 with the ability to engage patients, families, and clinicians effectively
High level of organization with the ability to manage multiple patients and priorities simultaneously
Proficiency with EMR systems and basic computer applications
Valid driver’s license and reliable transportation

Nice To Haves

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

Responsibilities

Serve as the primary 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 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 and support initiatives focused on improving outcomes and reducing readmissions