Care Transitions Navigator

Sanitas; Katy, Town of Texas (TX, WI); On-site; USD 42,000 - 70,000; Full time

Job summary

Sanitas is seeking a Case Management Coordinator to bridge hospital, primary care, and community services. The role focuses on patients with high ER use and recent discharges, coordinating follow-up and care plans to improve outcomes and satisfaction.

You will educate patients on care options, collaborate with care teams, and help remove barriers to access, while documenting actions in the EMR and tracking results for performance improvement.

Qualifications

• 3–5 years of experience in a clinical or community health setting.
• Experience in care coordination, discharge planning, or case management.
• Medical Assistant License or equivalent required.

Responsibilities

• Identify and engage patients with high ER utilization or recent hospital discharges.
• Coordinate and confirm timely post-ER or post-discharge follow-up appointments.
• Educate patients on appropriate 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

EMR systems

Microsoft Office

English communication

Spanish (preferred)

Creole (preferred)

Medical terminology

Healthcare navigation

Education

High school diploma

Tools

EMR software

Job description

Sanitas is seeking a Case Management Coordinator to bridge hospital, primary care, and community services. The role focuses on patients with high ER use and recent discharges, coordinating follow-up and care plans to improve outcomes and satisfaction.

You will educate patients on care options, collaborate with care teams, and help remove barriers to access, while documenting actions in the EMR and tracking results for performance improvement.