Care Transition Navigator - Home Health - FT

Join VitalCaring – Where Your Passion Changes Lives!

Are you looking for a career where compassion meets purpose? At VitalCaring, we’re more than a home health and hospice provider—we’re a family that supports, inspires, and uplifts both our patients and our team members.

Who We Are
Founded in 2021, VitalCaring has grown into a leading provider of home health and hospice services, with over 100 locations across the country. We are committed to fostering a culture of support, growth, and excellence for our team that is the backbone of how we ensure we deliver exceptional patient care.

Why Choose VitalCaring?

Drive Innovation. Deliver Impact - Join a mission-driven team where your work directly contributes to advancing patient care. As a key player in a forward-thinking healthcare organization, you’ll represent innovative solutions that truly make a difference for patients and families—today and into the future

Make a Meaningful Impact – Help patients and families navigate their healthcare journey with compassion and dignity.

Thrive in a Supportive Team – Work with a team who genuinely care and invest in your success.

Grow Your Career – Take advantage of advanced training, mentorship, and career development opportunities.

Competitive Pay & Benefits – Be rewarded for your dedication and expertise with a compensation package that truly reflects your value. Our benefits are thoughtfully designed to support your well-being—offering the flexibility, security, and resources you need to thrive both at work and in life. We celebrate success at every level, with meaningful recognition for both individual contributions and team achievements.

Health & Wellness
• Medical, Dental & Vision
• Pharmacy Benefits
• Virtual & Mental Health Support
• Flexible Spending Accounts (FSAs) & Health Savings Account (HSA)
• Supplemental Health & Life Insurance

Financial & Legal
• 401(k) with Company Match
• Employee Referral Program
• Prepaid Legal Plans
• Identity Theft Protection

Work-Life Balance & Perks
• Paid Time Off
• Pet Insurance
• Tuition & Continuing Education Reimbursement

Join VitalCaring Group and experience a company that invests in you every step of the way!

 

Job Summary

At VitalCaring, our team members transform lives and foster hope through genuine caring. As a Care Transition Navigator (CTN), you play a critical role in ensuring a safe, seamless transition from the acute care setting to home. You will conduct bedside assessments, identify high-risk medical and social needs, collaborate with hospital care teams, and coordinate timely, effective home health referrals. This role is essential to preventing avoidable rehospitalizations while delivering a compassionate, patient-centered experience. Every encounter reflects our values—trustworthy, capable, compassionate, proactive, and called.

Essential Functions

Clinical Assessment & Care Coordination

• Conduct onsite hospital bedside assessments within 24 hours of referral.
• Integrate evidence-based clinical guidelines to develop patient-centered transition plans.
• Engage with patients, caregivers, case managers, physicians, and inpatient teams to gather key information for discharge planning.
• Identify high-risk medical and social determinants of health needs and communicate them to the care team.
• Schedule a follow-up primary care appointment within 3 days post-discharge.
• Complete follow-up phone calls within 48 hours of discharge and document CTN Follow-Up Coordination notes in HCHB.
• Support strategies to reduce home health rehospitalizations through proactive communication and interventions.

Documentation & EMR Responsibilities

• Document CTN coordination notes to support admitting home health clinicians.
• Complete workflow tasks and assignments specific to the CTN role in the EMR.
• Receive and enter verbal orders in HCHB from licensed practitioners and ensure physician approval.
• Follow up on pending referrals to support timely home health admissions.

Interdisciplinary Collaboration

• Participate in care coordination with agency staff, contractors, patients, and referral partners.
• Communicate effectively with all providers involved in a patient’s plan of care.
• Educate patients and caregivers on engagement with the VitalCaring Connection (VCC) for virtual and telephonic care.
• Prepare for and participate in case conferences with other healthcare team members.

Professional Standards

• Meet all mandatory continuing education requirements.
• Demonstrate effective communication and interpersonal skills across the care team.
• Attend agency-sponsored in-service training sessions.
• Perform additional duties as assigned.

Qualifications

Education & Licensure

• Graduate of an accredited nursing program (RN, LVN/LPN) or an accredited Physical Therapy program (PT).
• Active RN, LVN/LPN, or PT license in state of employment; valid driver’s license required.
• May require completion of HHS Computer-Based Training depending on license category.

Experience & Skills

• Minimum of two years of clinical experience as an RN, PT, LVN, or LPN.
• One year of home health experience preferred.
• Strong nursing or PT clinical skills aligned with accepted standards of practice.
• Excellent interpersonal, communication, and decision-making skills.
• Proven relationship-building and territory management abilities.
• Proficiency with Microsoft Office, CRM platforms, and EMR systems preferred.

Additional Requirements

• Reliable transportation with current auto liability insurance.
• Ability to work a flexible schedule, including weekends based on referral partner needs.
• Comfortable spending 80% of time in assigned hospital or facility settings.