Care Transition Navigator
About The Position
The Care Transition Navigator (CTN) plays a critical role in ensuring safe, seamless transitions from the hospital to home health care. Working directly within assigned hospital systems, the CTN partners with case managers, physicians, patients, and families to coordinate care, reduce readmissions, and improve patient outcomes. This high-impact, relationship-driven role combines clinical insight, care coordination, and referral management to support patient success and agency growth. The position is field-based, with regular presence in assigned hospitals and healthcare facilities. It is a high-touch, patient-facing role in a fast-paced environment that calls for adaptability, critical thinking, proactive follow-through, and strong time management. Performance expectations are tied to patient outcomes and successful care transitions and admissions.
Requirements
- Active RN, LVN/LPN, or PT license in the state of employment, or compact eligibility if applicable.
- At least two 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 and ability to engage patients, families, and clinicians effectively.
- Strong organization and 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
- Home health or post-acute experience.
- Experience in home health, hospice, or post-acute care.
- Background working within hospital systems, such as 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 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.
- Balance hospital coordination, patient interactions, and documentation through effective time management.
Benefits
- 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.
- 401(k) with company match.
- Employee referral program.
- Prepaid legal services.
- Identity theft protection.
- Generous paid time off.
- Pet insurance.
- Tuition and continuing education reimbursement.
- Advanced training, mentorship, and career development opportunities.
- Competitive compensation package and recognition for individual and team achievements.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
