Care Transition Coordinator

Sanitas; Katy, Town of Texas (TX, WI); On-site; USD 60,000 - 90,000; Full time

Job summary

Sanitas in the Houston region is seeking a Case Management Coordinator to manage transitions of care for members post-discharge and with chronic conditions. The role involves coordinating follow-up care, creating personalized care plans, and educating patients and caregivers to prevent readmissions and improve health outcomes.

Key responsibilities include outreach within 24-72 hours, coordinating with PCPs, specialists, and home health agencies, and documenting all clinical interventions in the

Qualifications

• Strong understanding of chronic disease management and post-acute care processes.
• Ability to educate and empower members and caregivers using motivational interviewing techniques.
• Excellent verbal and written communication with interdisciplinary teams and community partners.
• Proven clinical problem-solving to identify barriers to care and appropriate transition plans.
• Accurate and timely documentation in EMR/care management platforms.

Responsibilities

• Conduct post-discharge outreach within 24-72 hours to assess needs and gaps in care.
• Coordinate follow-up appointments and post-acute services across care continuum.
• Develop individualized care plans based on program categories.
• Educate members and caregivers on red-flag symptoms and self-management strategies.
• Document all interactions and interventions in the care management system.

Skills

Clinical knowledge

Patient engagement

Communication

Problem solving

EMR documentation

Education

High school diploma or equivalent

Graduation from an MA program

MA national certification

CPR/BLS certification

Job description

Sanitas in the Houston region is seeking a Case Management Coordinator to manage transitions of care for members post-discharge and with chronic conditions. The role involves coordinating follow-up care, creating personalized care plans, and educating patients and caregivers to prevent readmissions and improve health outcomes.

Key responsibilities include outreach within 24-72 hours, coordinating with PCPs, specialists, and home health agencies, and documenting all clinical interventions in the