Care Transition Navigator
On-site · Fort Worth, Texas, United States
Job Summary
Coordinate hospital-to-home health transitions as the primary liaison among hospital teams, patients, and VitalCaring clinicians to ensure safe, seamless discharge and continued care. Perform bedside assessments to identify clinical needs and barriers to discharge; partner with case managers and physicians to develop and execute patient-centered transition plans; drive timely admissions by coordinating referrals and smooth handoffs to home health services; maintain strong relationships with hospital partners through consistent communication and follow-through; conduct post-discharge follow-up within 48 hours and ensure timely primary care coordination; work in a field-based, high-touch environment focused on improving patient outcomes and reducing readmissions; require active RN/LVN/PT licensure, clinical experience in care coordination or post-acute settings, EMR proficiency (e.g., HCHB or similar), and a valid driver’s license.
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
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