Care Transitions Specialist for High-Risk Patients

Paycom - ATS; Surprise (AZ); On-site; USD 40,000 - 65,000; Full time

Job summary

Paycom - ATS seeks a Case Management Coordinator for Transitions of Care to support patients with high ER utilization and post-discharge follow-up. The role connects hospital, primary care, and community resources to improve outcomes.

Responsibilities include coordinating timely follow-ups, educating patients on care settings, documenting in the EMR, and collaborating with PCPs, hospital staff, and payors to implement care plans.

Qualifications

• Strong understanding of medical terminology and healthcare navigation.
• Experience in care coordination, discharge planning, or case management.
• Excellent verbal, written, and interpersonal communication skills.

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.
• 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

Care coordination

Healthcare navigation

Verbal communication

Written communication

Interpersonal skills

EMR proficiency

Education

High school diploma or equivalent

Tools

EMR systems

Microsoft Office

Job description

Paycom - ATS seeks a Case Management Coordinator for Transitions of Care to support patients with high ER utilization and post-discharge follow-up. The role connects hospital, primary care, and community resources to improve outcomes.

Responsibilities include coordinating timely follow-ups, educating patients on care settings, documenting in the EMR, and collaborating with PCPs, hospital staff, and payors to implement care plans.