Care Transition Navigator

Care Transition Navigator (CTN) – Home HealthField-Based | Hospital-Focused | Patient Transition & Care Coordination Role OverviewThe 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. Key ResponsibilitiesServe as the primary liaison between hospital teams, patients, and VitalCaring clinicians to ensure seamless transitions from hospital to homeConduct bedside assessments to identify clinical needs, risk factors, and barriers to successful dischargePartner with case managers and physicians to develop and execute safe, patient-centered transition plansDrive timely admissions by coordinating referrals and ensuring smooth handoffs into home health servicesBuild strong, trusted relationships with hospital partners through consistent communication and follow-throughComplete post-discharge follow-up within 48 hours and ensure timely primary care coordinationCollaborate with internal teams and support initiatives focused on improving outcomes and reducing readmissions Required QualificationsActive 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 preferredExperience in healthcare coordination, case management, clinical care, or hospital-based rolesStrong understanding of patient care transitions, discharge planning, or post-acute servicesDemonstrated ability to build relationships with healthcare providers and interdisciplinary teamsExcellent communication skills with the ability to engage patients, families, and clinicians effectivelyHigh level of organization with the ability to manage multiple patients and priorities simultaneouslyProficiency with EMR systems and basic computer applicationsValid driver’s license and reliable transportation Preferred QualificationsExperience in home health, hospice, or post-acute careBackground working within hospital systems (case management, discharge planning, or bedside coordination)Knowledge of CMS guidelines and readmission reduction strategiesFamiliarity with Homecare Homebase (HCHB) or similar EMR systems Work Environment & ExpectationsField-based role with regular presence in assigned hospitals and healthcare facilitiesHigh-touch, patient-facing position requiring strong interpersonal and clinical communication skillsFast-paced environment requiring adaptability, critical thinking, and proactive follow-throughPerformance expectations tied to both patient outcomes and successful care transitions/admissionsRequires strong time management to balance hospital coordination, patient interaction, and documentation