Care Transition Coordinator - Post-Discharge & Chronic Care

SANITAS OF TEXAS LLC; Surprise (AZ); On-site; USD 45,000 - 65,000; Full time

Job summary

Sanitas is seeking a Case Management Coordinator to manage the transition of care for members post-discharge and those with chronic conditions, coordinating follow-up care, creating personalized care plans, and educating patients and caregivers to prevent hospital readmissions and improve health outcomes.

This role collaborates with primary care providers, specialists, home health agencies, and community resources to ensure seamless continuity of care and accurate documentation in the EMR.

Qualifications

• High school diploma or equivalent
• Graduation from an MA program
• Strong knowledge of chronic disease management
• Excellent communication with patients and teams

Responsibilities

• Post-discharge outreach within 24-72 hours to assess needs and gaps in care
• Coordinate follow-up appointments and post-acute services across providers
• Develop individualized care plans for assigned program categories
• Educate patients and caregivers using motivational interviewing
• Document assessments and interventions accurately in EMR
• Escalate clinical issues when necessary

Skills

Clinical knowledge

Patient engagement

Communication

Problem solving

EMR documentation

Education

High school diploma or equivalent

Medical Assistant program

Tools

EMR systems

Care management platform

Job description

Sanitas is seeking a Case Management Coordinator to manage the transition of care for members post-discharge and those with chronic conditions, coordinating follow-up care, creating personalized care plans, and educating patients and caregivers to prevent hospital readmissions and improve health outcomes.

This role collaborates with primary care providers, specialists, home health agencies, and community resources to ensure seamless continuity of care and accurate documentation in the EMR.