Care Transition Navigator

Join Vital Caring – Where Your Passion Changes Lives!

Are you looking for a career where compassion meets purpose? At Vital Caring, 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.

Founded in 2021, Vital Caring 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.

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.

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

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

• Paid Time Off
• Pet Insurance
• Tuition & Continuing Education Reimbursement

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

At Vital Caring, 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.

• 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.

• 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.

• 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 Vital…