Care Transition Navigator

VitalCaring Group•West Palm Beach, FL

22h•Onsite

About The Position

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.

Requirements

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.
Minimum of two years of clinical experience as an RN, PT, LVN, or LPN.
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.
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.

Nice To Haves

One year of home health experience preferred.
Proficiency with Microsoft Office, CRM platforms, and EMR systems preferred.

Responsibilities

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 VitalCaring Connection (VCC) for virtual and telephonic care.
Prepare for and participate in case conferences with other healthcare team members.
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.