Care Transitions Coordinator | Post-Discharge Navigator

Sanitas; Katy (TX); On-site; USD 52,000 - 76,000; Full time

Job summary

Sanitas seeks a Case Management Coordinator – Transitions of Care to manage high ER utilizers and patients transitioning from inpatient facilities. You will support value-based care goals by facilitating timely follow-up and connecting patients with Sanitas and community resources.

The role bridges hospital, primary care, and community services to improve outcomes and satisfaction. Requires 3–5 years in clinical or community health, High school diploma, and a Medical Assistant License; bilingual

Qualifications

• High school graduate or equivalent required.
• 3–5 years in clinical or community health setting.
• Experience in care coordination, discharge planning, or case management.
• Medical Assistant License required.
• Proficient in EMR, Microsoft Office, and documentation practices.

Responsibilities

• Identify and engage patients with high ER utilization or recent discharges.
• Coordinate timely post-ER or post-discharge follow-up.
• Educate patients on care settings and how to navigate Sanitas services.
• Work closely with PCPs, hospital staff, and payors to create and follow through on care plans.
• Address barriers to care such as transportation, medication access, or lack of support at home.
• Document care plans, patient interactions, and interventions in the EMR.
• Track patient outcomes and contribute to performance improvement initiatives.
• Provide culturally and linguistically appropriate education to patients and caregivers.
• Encourage patient engagement and build rapport through consistent communication.

Skills

Medical terminology

Communication

Interpersonal skills

Team collaboration

Social determinants of health

Education

High school diploma or equivalent

Tools

EMR systems

Microsoft Office

Job description

Sanitas seeks a Case Management Coordinator – Transitions of Care to manage high ER utilizers and patients transitioning from inpatient facilities. You will support value-based care goals by facilitating timely follow-up and connecting patients with Sanitas and community resources.

The role bridges hospital, primary care, and community services to improve outcomes and satisfaction. Requires 3–5 years in clinical or community health, High school diploma, and a Medical Assistant License; bilingual