Care Transition Navigator - Houston Med Center

About the role

Founded in 2021, VitalCaring is a leading provider of home health and hospice services with over 100 locations across the country. We foster a culture of support, growth, and excellence to deliver exceptional patient care. As a Care Transition Navigator, you’ll drive innovation and deliver impact by coordinating seamless transitions from hospital to home health, reducing readmissions, and improving patient outcomes.

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

Required Qualifications

• 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

Preferred Qualifications

• 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

Work Environment & Expectations

• Field-based role with regular presence in assigned hospitals and healthcare facilities
• High-touch, patient-facing position requiring strong interpersonal and clinical communication skills
• Fast-paced environment requiring adaptability, critical thinking, and proactive follow-through
• Performance expectations tied to both patient outcomes and successful care transitions/admissions
• Requires strong time management to balance hospital coordination, patient 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