Case Management Coordinator - Transitions of Care

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

Job SummaryCase Management Coordinator – Transitions of Care plays a vital role in managing patients who frequently use the emergency room or are transitioning from inpatient facilities. This position supports value-based care goals by facilitating timely follow-up, reducing unnecessary utilization, and connecting patients with appropriate Sanitas and community-based resources. The role bridges care between hospital settings, primary care, and community services to improve patient outcomes and satisfaction.Essential Job FunctionsReasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.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 available 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.Supervisory ResponsibilitiesThis position has no supervisory responsibilitiesRequired EducationHigh school graduate or equivalent.Required Experience3–5 years of experience in a clinical or community health setting.Experience in care coordination, discharge planning, or case managementRequired Licenses and CertificationsMedical Assistant LicenseRequired Knowledge, Skills, and AbilitiesStrong understanding of medical terminology and healthcare navigation.Excellent verbal, written, and interpersonal communication skills.Familiarity with social determinants of health and community resources.Proficiency in EMR systems, Microsoft Office, and documentation practices.Ability to work independently and in collaboration with interdisciplinary teamsPreferred QualificationsKnowledge of managed care and value-based care models.Experience working with vulnerable or high-risk patient populations.Financial ResponsibilitiesNone of the above - This position does not currenlty handle physical money or negotiate contractsBudget ResponsibilitiesThis position does not currently have Budget ResponsibilityLanguagesEnglish: AdvancedSpanish: PreferredCreole: PreferredTravelRequired to visit the assigned centers, further emphasizing their commitment to maintaining a unified and patient-centric approach across various locations.Physical DemandsThe physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.Includes corporate and medical center administrative staff whose primary duties are office-based. These positions generally require prolonged sitting, computer use, occasional standing and walking, and the ability to lift or carry up to 20 pounds, with occasional travel between company locations as needed.Environmental ConditionsInside: The employee is subject to environmental conditions, protection from weather conditions but not necessarily from temperature changes. The worker is subject to noise; there may be sufficient noise to cause the worker to shout to be heard above ambient noise level.Physical/Environmental ActivitiesPlease indicate with an X the frequency for the activities that apply to the essential functions of the job based on the chart below. Please select Not Required for physical demands that aren’t essential to job performance.Must be able to travel to multiple locations for work (i.e. travel to attend meetings, events, conferences). Not RequiredMay be exposed to outdoor weather conditions of cold, heat, wet, and humidity. Not RequiredMay be exposed to outdoor or warehouse conditions of loud. noises, vibration, fumes, dust, odors, and mists. Not RequiredMust be able to ascend and descend ladders, stairs, or other equipment. Not RequiredSubject to exposure to hazardous material. Not Required