Case Management Coordinator - Transitions of Care

Sanitas Medical Centers; Surprise (AZ); On-site; USD 55,000 - 75,000; Full time

Job summary

Sanitas Medical Centers is seeking a Case Management Coordinator – Transitions of Care to support patients who frequently use the emergency department or are transitioning from inpatient facilities. The role helps achieve value-based care goals by enabling timely follow-up and connecting patients with Sanitas and community resources.

The position bridges care between hospital, primary care, and community services to improve patient outcomes and satisfaction, with EMR documentation and

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.

Responsibilities

• Identify and engage high ER-utilizing patients.
• Coordinate timely post-ER or post-discharge follow-ups.
• Educate patients on care settings and Sanitas services.
• Collaborate with PCPs, hospital staff, and payors on care plans.
• Document care plans and encounters in the EMR.
• Track patient outcomes and support performance improvement initiatives.
• Provide culturally and linguistically appropriate education.
• Encourage patient engagement through consistent communication.

Skills

Care coordination

Discharge planning

EMR documentation

Patient education

Communication

Education

High school diploma or equivalent

Tools

EMR

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