Care Transition Specialist

SANITAS OF TEXAS LLC; Katy (TX); On-site; USD 52,000 - 72,000; Full time

Job summary

Sanitas of Texas LLC is seeking a Case Management Coordinator to manage post-discharge transitions and chronic care coordination. You will develop personalized care plans, educate patients and caregivers, and work with primary care teams to prevent readmissions and improve outcomes.

The role emphasizes strong documentation, motivational interviewing, and collaboration with healthcare partners to ensure seamless care across the continuum.

Qualifications

• Post-discharge outreach within 24–72 hours to assess needs and gaps in care.
• Coordinate follow-up appointments with providers and community resources.
• Educate members and caregivers using motivational interviewing.
• Document all interactions in care management platform in a timely, compliant manner.

Responsibilities

• Manage transition of care for post-discharge and chronic conditions.
• Develop individualized care plans and escalate clinical issues as needed.
• Collaborate with primary care, specialists, and community resources to ensure continuity of care.

Skills

Motivational interviewing

Patient engagement

Communication

Clinical problem-solving

EMR documentation

Education

High school diploma or equivalent

Graduate of an accredited Medical Assistant program

CCM credential (preferred)

Tools

EMR systems

Care management platform

Job description

Sanitas of Texas LLC is seeking a Case Management Coordinator to manage post-discharge transitions and chronic care coordination. You will develop personalized care plans, educate patients and caregivers, and work with primary care teams to prevent readmissions and improve outcomes.

The role emphasizes strong documentation, motivational interviewing, and collaboration with healthcare partners to ensure seamless care across the continuum.