Caring Transitions Jobs in Usa

Join VitalCaring Where Your Passion Changes Lives!

Are you looking for a career where compassion meets purpose? At VitalCaring, we're more than a home health and hospice providerwe're a family that supports, inspires, and uplifts both our patients and our team members.

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.

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 familiestoday 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-beingoffering 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.

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

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

Work-Life Balance & Perks Paid Time Off Pet Insurance Tuition & Continuing Education Reimbursement

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

Job Summary

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 valuestrustworthy, capable, compassionate, proactive, and called.

Essential Functions

Clinical Assessment & Care Coordination

• 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.

Documentation & EMR Responsibilities

• 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.

Interdisciplinary Collaboration

• 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.

Professional Standards

• 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.

Qualifications

Education & Licensure

• 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.

Experience & Skills

• Minimum of two years of clinical experience as an RN, PT, LVN, or LPN.
• One year of home health experience preferred.
• 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.
• Proficiency with Microsoft Office, CRM platforms, and EMR systems preferred.

Additional Requirements

• 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.

• 
  
• Medical: Multiple plan options.
  
• Dental: Delta Dental or reimbursement account for flexible coverage.
  
• Vision: Affordable plan with national network.
  
• Pre-Tax Savings: HSA and FSAs for eligible expenses.
  
• Retirement: Competitive retirement package to secure your future.
  

The registered nurse (RN) is accountable for the coordination of nursing care, including direct patient care, patient/family education and transitions of care. The RN supports professional nursing practice across practice settings and across the continuum of care to meet the needs of the patient and family. The RN will function within the Mayo Clinic Nursing Professional Practice Model, which includes accountability for planning, implementing, evaluating and communicating all phases of nursing care for assigned patients. The ANA Nursing: Scope and Standards of Practice provide a basis for the practice of the RN. The RN provides leadership through activities such as preceptor role, informal leadership roles, and quality improvement efforts. The RN delegates patient care according to skill level, experience, patient acuity, fiscal accountability, and adequacy of resources. The RN possesses excellent communication skills; is skillful in mentoring and teaching; and may participate on committees or projects. A subset of employees may be required to drive their personal vehicle as a part of the responsibility of their role. 

This role is eligible for TN sponsorship. Successful sponsorship will require state licensure and completion of the VisaScreen or equivalent certification.

Graduate of a nursing program.

All entry-level associate degree registered nurses with a RN start date of April 1, 2020 and after must provide documented evidence of program completion of a baccalaureate degree in nursing program within five years from the last day of the month of the RN start date.

All entry-level associate degree registered nurses with a RN start date prior to April 1, 2020 must provide documented evidence of program completion of a baccalaureate degree in nursing program as stipulated by the degree requirement program in place at time of hire.

One year of RN experience in an applicable care setting or one year of LPN experience at Mayo Clinic is preferred.

Excellent communication skills (verbal and written). Experience working in a team environment. Computer skills required, prior experience with electronic medical record systems preferred. Ability to work flexible hours, which may include days, evenings, nights, holidays, and weekends and on-call. Ability to adapt to unpredictable situations within the work setting. Demonstrated leadership, effective communicator, and excellent critical thinking skills.

License or Certification: Current RN license by applicable state requirements. Maintains Basic Life Support (BLS) competency from one of the following programs: American Heart Association or American Red Cross. Positions that are not on campus may not require current Basic Life Support (BLS) competency as determined by the work area.

Additional state licensure(s) and/or specialty certification/training as required by the work area.
 

• 
  
• Medical: Multiple plan options.
  
• Dental: Delta Dental or reimbursement account for flexible coverage.
  
• Vision: Affordable plan with national network.
  
• Pre-Tax Savings: HSA and FSAs for eligible expenses.
  
• Retirement: Competitive retirement package to secure your future.
  

The registered nurse (RN) is accountable for the coordination of nursing care, including direct patient care, patient/family education and transitions of care. The RN supports professional nursing practice across practice settings and across the continuum of care to meet the needs of the patient and family. The RN will function within the Mayo Clinic Nursing Professional Practice Model, which includes accountability for planning, implementing, evaluating and communicating all phases of nursing care for assigned patients. The ANA Nursing: Scope and Standards of Practice provide a basis for the practice of the RN. The RN provides leadership through activities such as preceptor role, informal leadership roles, and quality improvement efforts. The RN delegates patient care according to skill level, experience, patient acuity, fiscal accountability, and adequacy of resources. The RN possesses excellent communication skills; is skillful in mentoring and teaching; and may participate on committees or projects. A subset of employees may be required to drive their personal vehicle as a part of the responsibility of their role. 

This role is eligible for TN sponsorship. Successful sponsorship will require state licensure and completion of the VisaScreen or equivalent certification.

Graduate of a nursing program.

All entry-level associate degree registered nurses with a RN start date of April 1, 2020 and after must provide documented evidence of program completion of a baccalaureate degree in nursing program within five years from the last day of the month of the RN start date.

All entry-level associate degree registered nurses with a RN start date prior to April 1, 2020 must provide documented evidence of program completion of a baccalaureate degree in nursing program as stipulated by the degree requirement program in place at time of hire.

One year of RN experience in an applicable care setting or one year of LPN experience at Mayo Clinic is preferred.

Excellent communication skills (verbal and written). Experience working in a team environment. Computer skills required, prior experience with electronic medical record systems preferred. Ability to work flexible hours, which may include days, evenings, nights, holidays, and weekends and on-call. Ability to adapt to unpredictable situations within the work setting. Demonstrated leadership, effective communicator, and excellent critical thinking skills.

License or Certification: Current RN license by applicable state requirements. Maintains Basic Life Support (BLS) competency from one of the following programs: American Heart Association or American Red Cross. Positions that are not on campus may not require current Basic Life Support (BLS) competency as determined by the work area.

Additional state licensure(s) and/or specialty certification/training as required by the work area.
 

• 
  
• Medical: Multiple plan options.
  
• Dental: Delta Dental or reimbursement account for flexible coverage.
  
• Vision: Affordable plan with national network.
  
• Pre-Tax Savings: HSA and FSAs for eligible expenses.
  
• Retirement: Competitive retirement package to secure your future.
  

The registered nurse (RN) is accountable for the coordination of nursing care, including direct patient care, patient/family education and transitions of care. The RN supports professional nursing practice across practice settings and across the continuum of care to meet the needs of the patient and family. The RN will function within the Mayo Clinic Nursing Professional Practice Model, which includes accountability for planning, implementing, evaluating and communicating all phases of nursing care for assigned patients. The ANA Nursing: Scope and Standards of Practice provide a basis for the practice of the RN. The RN provides leadership through activities such as preceptor role, informal leadership roles, and quality improvement efforts. The RN delegates patient care according to skill level, experience, patient acuity, fiscal accountability, and adequacy of resources. The RN possesses excellent communication skills; is skillful in mentoring and teaching; and may participate on committees or projects. A subset of employees may be required to drive their personal vehicle as a part of the responsibility of their role. 

This role is eligible for TN sponsorship. . Successful sponsorship will require state licensure and completion of the VisaScreen or equivalent certification.

Graduate of a nursing program.

All entry-level associate degree registered nurses with a RN start date of April 1, 2020 and after must provide documented evidence of program completion of a baccalaureate degree in nursing program within five years from the last day of the month of the RN start date.

All entry-level associate degree registered nurses with a RN start date prior to April 1, 2020 must provide documented evidence of program completion of a baccalaureate degree in nursing program as stipulated by the degree requirement program in place at time of hire.

One year of RN experience in an applicable care setting or one year of LPN experience at Mayo Clinic is preferred.

Excellent communication skills (verbal and written). Experience working in a team environment. Computer skills required, prior experience with electronic medical record systems preferred. Ability to work flexible hours, which may include days, evenings, nights, holidays, and weekends and on-call. Ability to adapt to unpredictable situations within the work setting. Demonstrated leadership, effective communicator, and excellent critical thinking skills.

License or Certification: Current RN license by applicable state requirements. Maintains Basic Life Support (BLS) competency from one of the following programs: American Heart Association or American Red Cross. Positions that are not on campus may not require current Basic Life Support (BLS) competency as determined by the work area.

Additional state licensure(s) and/or specialty certification/training as required by the work area.
 

Thriving, well-known hospital in the beautiful state of Vermont is in search for a Nurse Director to oversee Clinical Practices.

Responsibilities include: Clinical responsibility for nursing staff within the Physician Services Clinics and Inpatient Care Management departments. Responsible for employee engagement and satisfaction.

Position offers excellent benefits including: Health, Dental, Vision, Retirement with Match, etc.

Must-Have

• Masters Degree in Nursing
• 5+ years of outpatient clinic experience as well as 3+ years of supervisory experience.

For more information on this RN Director opportunity or other Healthcare Management positions nationwide, please send us an updated resume and the best time to reach you.

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