Care Transition & Chronic Care Coordinator

Sanitas Medical Centers; Surprise (AZ); On-site; USD 52,000 - 72,000; Full time

Job summary

Sanitas Medical Centers is seeking a Case Management Coordinator to oversee the transition of care for members after discharge and for those with chronic conditions, coordinating follow-up care and developing personalized care plans to prevent readmissions and reduce over-utilization.

The role involves educating patients and caregivers using motivational interviewing, arranging post-acute services, collaborating with primary care providers, specialists, and home health agencies, and documenting

Qualifications

• Experience in care coordination or case management.
• Ability to educate patients and caregivers using motivational interviewing.
• Familiarity with discharge planning and follow-up processes.

Responsibilities

• Post-discharge outreach within 24-72 hours to assess needs and gaps in care.
• Coordinate follow-up appointments with providers and home health services.
• Develop individualized care plans based on program categories for chronic conditions.
• Educate patients and caregivers using motivational interviewing and self-management guidance.
• Document all interactions in the care management platform to ensure compliance and accuracy.

Skills

Care coordination

Patient education

Motivational interviewing

Discharge planning

Documentation

Tools

Care management platform

Job description

Sanitas Medical Centers is seeking a Case Management Coordinator to oversee the transition of care for members after discharge and for those with chronic conditions, coordinating follow-up care and developing personalized care plans to prevent readmissions and reduce over-utilization.

The role involves educating patients and caregivers using motivational interviewing, arranging post-acute services, collaborating with primary care providers, specialists, and home health agencies, and documenting