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VitalCaring

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Care Transition Navigator

Open 26d posting dated 2 weeks ago

Summary

Coordinates patient transitions from hospitals to home health care, assessing needs, planning discharges, and ensuring smooth handoffs to improve outcomes and reduce readmissions.

Join VitalCaring – Where Your Passion Changes Lives!

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.

What Sets Us Apart?

  • 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.

Care Transition Navigator (CTN) – Home Health

Field-Based | Hospital-Focused | Patient Transition & Care Coordination

Role Overview

The 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 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

All employment decisions are made without regard to race, color, religion, sex, gender identity or expression, sexual orientation, national origin, age, disability, veteran status, or any other protected characteristic. Candidates are evaluated based on job-related qualifications, skills, and business needs.

#TalrooSales
#AppSales

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What this application asks

greenhouse

First Name, Last Name, Email, Phone, Resume/CV

  • Preferred First Name optional
  • Are you currently or have you previously been employed by VitalCaring or At Home Healthcare? choose any
  • Would you like to opt in to receive job related updates by Email & SMS? Standard data rates may apply. choose one
  • LinkedIn Profile optional
  • Are you legally authorized to work in the United States? choose one
  • Will you now or in the future require employer sponsorship to work in the United States? choose one
  • Are you at least 18 years of age? choose one
  • Were you referred by a current VitalCaring or At Home Healthcare team member? choose one
  • If you were referred, please indicate their name here: optional
  • Do you have a valid drivers license? choose one
  • Do you have reliable transportation and active auto insurance to support a field-based role? choose one
  • Do you currently hold an active RN, LVN/LPN, or PT license in the state of employment (or compact eligibility)? choose one
  • Please select your licensure from the list below: choose one
  • Has your professional license and/or certification ever been suspended, revoked, or subject to disciplinary action? choose one
  • In which state(s) is your license currently active and unrestricted? choose one
  • By selecting Yes, I confirm my RN, LVN/LPN, or PT license is currently active, unrestricted, and eligible for employment in this role. choose one
  • How many years of clinical experience do you have? choose one
  • Do you have experience in a field-based, referral-driven healthcare sales role? choose one
  • Which of the following best describes your most recent sales experience? (Select one) choose one
  • This role requires daily in-person visits to referral sources (physicians, hospitals, facilities). Are you comfortable working in a field-based role? choose one
  • Do you have experience working in a hospital setting (case management, discharge planning, bedside coordination, or similar)? choose one
  • Describe your experience coordinating patient discharges or transitions of care. What was your role? written answer · optional
  • What is your state of residence? choose one
  • What is your ZIP code of residence?
  • What are your compensation expectations for your next role (base + incentive)?
  • How did you hear about this opportunity?
  • Have you ever been excluded, suspended, or otherwise deemed ineligible to participate in any state or federal healthcare program (including Medicare or Medicaid)? choose one
  • I certify that all of the information I have provided is true and complete, and I understand that any falsification or omission of information may disqualify me from further consideration for employment or, if hired, may result in termination regardless of the time elapsed before discovery. choose one

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