Care Transition Navigator

VitalCaring Group•Lafayette, LA

8d•Onsite

About The Position

The Care Transition Navigator (CTN) is a field-based, hospital-focused role that ensures safe, seamless transitions from hospital to home health care. The position works within assigned hospital systems and partners with case managers, physicians, patients, families, and VitalCaring clinicians to coordinate care, reduce readmissions, and improve patient outcomes. It combines clinical insight, care coordination, and referral management to support patient success and agency growth. The role involves regular presence in assigned hospitals and healthcare facilities and frequent interaction with patients and care teams. It is a fast-paced position requiring adaptability, critical thinking, proactive follow-through, and strong time management to balance hospital coordination, patient interactions, and documentation. Performance expectations are tied to patient outcomes and successful care transitions and admissions.

Requirements

Hold an active RN, LVN/LPN, or PT license in the state of employment, or have compact eligibility if applicable.
Have a minimum of two years of clinical experience.
Have experience in healthcare coordination, case management, clinical care, or hospital-based roles.
Have a strong understanding of patient care transitions, discharge planning, or post-acute services.
Demonstrate the ability to build relationships with healthcare providers and interdisciplinary teams.
Have excellent communication skills and the ability to engage patients, families, and clinicians effectively.
Have strong organizational skills and the ability to manage multiple patients and priorities simultaneously.
Be proficient with EMR systems and basic computer applications.
Have a 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, including 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.
Coordinate referrals and smooth handoffs into home health services to drive timely admissions.
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.