Case Management Coordinator - Transitions of Care

Sanitas Medical Centers; Katy (TX); On-site; USD 65,000 - 77,000; Full time

Job summary

Sanitas Medical Centers is seeking a Case Management Coordinator – Transitions of Care to support patients who frequently use the ER or are transitioning from inpatient facilities. The role coordinates timely follow-up, reduces unnecessary utilization, and connects patients with Sanitas and community resources to improve outcomes.

The position works to bridge care between hospital settings, primary care, and community services, ensuring effective communication and care plan follow-through to

Qualifications

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

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.
• Document care plans, patient interactions, and interventions in the EMR.
• Collaborate with PCPs, hospital staff, and payors to create and follow through on care plans.

Skills

Care coordination

Communication skills

Patient education

EMR documentation

Education

High school diploma

Tools

EMR systems

Job description

Job Summary

Case 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.

Job Summary

Case 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 Functions

Reasonable 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 Responsibilities

This position has no supervisory responsibilities

Required Education

High school graduate or equivalent.

Required Experience

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