Care Transition & Chronic Care Coordinator

Paycom; Town of Florida (NY); On-site; USD 60,000 - 85,000; Full time

Job summary

Sanitas is a global healthcare organization expanding across the United States. The Case Management Coordinator manages the transition of care for members post-discharge and those with chronic conditions, coordinating follow-up care and educating patients and caregivers.

This role requires strong clinical knowledge, motivational interviewing skills, and the ability to document in EMR systems, ensuring high-quality, coordinated care and reduced readmissions.

Qualifications

• Clinical knowledge of chronic disease management and post-acute care processes.
• Motivational interviewing to educate and empower members and caregivers.
• Strong communication with patients, care teams, and community partners.

Responsibilities

• Post-discharge outreach within 24–72 hours to assess needs and gaps in care.
• Coordinate follow-up appointments with primary care, specialists, home health, and community resources.
• Develop individualized care plans for chronic conditions and escalate clinical issues as needed.
• Educate members and caregivers using motivational interviewing techniques.
• Document assessments and interventions accurately in the EMR.

Skills

Clinical knowledge

Patient engagement

Communication

Problem solving

EMR documentation

Education

High school diploma or equivalent

Graduation from an MA program

Tools

EMR/EHR

Job description

Sanitas is a global healthcare organization expanding across the United States. The Case Management Coordinator manages the transition of care for members post-discharge and those with chronic conditions, coordinating follow-up care and educating patients and caregivers.

This role requires strong clinical knowledge, motivational interviewing skills, and the ability to document in EMR systems, ensuring high-quality, coordinated care and reduced readmissions.