Care Transition Navigator - Weekend

About the role

Join VitalCaring - Where Your Passion Changes Lives!

What Sets Us Apart?

Meaningful work. A flexible schedule. Benefits that recognize your commitment.

This is a 16-hour-per-week weekend position designed for compassionate professionals who want to make a meaningful difference in the lives of patients and their families while maintaining balance in their own lives.

We value the time, heart, and dedication you bring to home health & hospice care-and we want our benefits to reflect that.

• 6 paid PTO days per year to rest, recharge, and care for yourself
• Company-designated holidays are truly yours - no PTO is required to take these days off
• 401(k) eligibility, subject to applicable plan terms and eligibility requirements

Because caring for others starts with making sure you have the support and time you need, too.

Care Transition Navigator (CTN) - Home Health - Weekend Sat/Sun

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

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