Care Transition Navigator

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Care Transition Navigator
Sulphur Springs, Texas, United States
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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 - Greenville / Commerce, TX
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.
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