Care Transitions Lead: Inpatient Discharge & Coordination

Sanitas Medical Centers; San Antonio (TX); On-site; USD 60,000 - 82,000; Full time

Job summary

Sanitas Medical Centers in San Antonio, TX is seeking a Case Management Coordinator – Inpatient to oversee discharge planning and ensure smooth patient transitions from inpatient care. You will coordinate with hospitalists, post-acute providers, and payor teams to develop discharge plans and arrange follow-up care.

The role emphasizes reducing readmissions, addressing barriers to care, educating patients and families, documenting care in the EMR, and contributing to process improvements across

Qualifications

• High school diploma or equivalent.
• 3–5 years of experience in clinical, case management, or community health settings.
• Experience in inpatient discharge planning or care coordination.

Responsibilities

• Initiate discharge planning upon notification of patient admission.
• Engage patients at inpatient or post-acute facilities and assess discharge readiness.
• Collaborate with Hospitalists, discharge planners, and payer care teams to develop discharge plans.
• Coordinate timely follow-up appointments with PCPs and specialists per discharge instructions.
• Educate patients and families about care instructions, resources, and home-based options.
• Identify and address barriers to safe discharge, including transportation and social needs.
• Document interactions, plans, and care coordination activities in the EMR.
• Monitor and report patient outcomes and care effectiveness to interdisciplinary teams.
• Facilitate communication between providers, facilities, and community-based organizations.
• Contribute to process improvement initiatives related to care transitions.

Skills

Discharge planning

Care coordination

EMR documentation

Provider communication

Patient education

Education

High school diploma

Tools

EMR/EHR

Job description

Sanitas Medical Centers in San Antonio, TX is seeking a Case Management Coordinator – Inpatient to oversee discharge planning and ensure smooth patient transitions from inpatient care. You will coordinate with hospitalists, post-acute providers, and payor teams to develop discharge plans and arrange follow-up care.

The role emphasizes reducing readmissions, addressing barriers to care, educating patients and families, documenting care in the EMR, and contributing to process improvements across