Care Transitions Specialist - ER & Discharge

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 - Transitions of Care to support high‑ER utilizers and patients transitioning from inpatient care. You will facilitate timely follow-ups, help navigate Sanitas services, and connect patients with community resources to improve outcomes.

You will collaborate with PCPs, hospital staff, and payors to develop comprehensive care plans and address barriers such as transportation or access to medications.

Qualifications

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

Medical terminology

Healthcare navigation

Verbal & written communication

Interpersonal skills

Social determinants of health

EMR systems

Microsoft Office

Documentation practices

Independent & collaborative work

Education

High school graduate or equivalent

Tools

EMR systems

Microsoft Office

Documentation practices

Job description

SANITAS OF TEXAS LLC is seeking a Case Management Coordinator - Transitions of Care to support high‑ER utilizers and patients transitioning from inpatient care. You will facilitate timely follow-ups, help navigate Sanitas services, and connect patients with community resources to improve outcomes.

You will collaborate with PCPs, hospital staff, and payors to develop comprehensive care plans and address barriers such as transportation or access to medications.