Care Transition Specialist

Paycom; Country Walk (FL); On-site; USD 65,000 - 85,000; Full time

Job summary

Sanitas is seeking a Case Management Coordinator to manage post-discharge transitions and chronic care through personalized plans and caregiver education. The role focuses on preventing readmissions, coordinating follow-up care, and ensuring smooth care continuity across the health system.

Required education includes a nationally accredited MA program and active MA certification, with CPR/BLS. English fluency is essential, Spanish/Creole bilingualism is preferred, and no travel is required.

Qualifications

• High school diploma or equivalent.
• Graduation from a nationally accredited Medical Assistant (MA) program.
• Active MA national certification.
• CPR/BLS for Healthcare Providers is required.

Responsibilities

• Post-discharge outreach within 24–72 hours to assess needs and gaps in care.
• Coordinate follow-up appointments with PCPs, specialists, home health, and community resources.
• Develop individualized care plans based on program categories and risk factors.
• Educate patients and caregivers using motivational interviewing to reduce over-utilization.
• Document interactions and interventions in the EMR to ensure compliance and continuity of care.

Skills

Clinical knowledge

Motivational interviewing

Communication skills

Problem solving

EMR documentation

Education

MA program graduation

CPR/BLS certification

Tools

EMR systems

Job description

Sanitas is seeking a Case Management Coordinator to manage post-discharge transitions and chronic care through personalized plans and caregiver education. The role focuses on preventing readmissions, coordinating follow-up care, and ensuring smooth care continuity across the health system.

Required education includes a nationally accredited MA program and active MA certification, with CPR/BLS. English fluency is essential, Spanish/Creole bilingualism is preferred, and no travel is required.