Case Management RN

Sanitas Medical Centers; Lake Worth (TX); On-site; USD 65,000 - 85,000; Full time

Job summary

Sanitas Medical Centers is seeking a Case Management RN to oversee the transition of care for post-discharge and chronic condition patients. You will coordinate follow-up, develop personalized care plans, and educate patients to prevent readmissions and improve health outcomes.

Responsibilities include timely post-discharge outreach, coordinating with providers and home health agencies, implementing care plans, and documenting interactions in the care management platform in compliance with

Qualifications

• RN with responsibility for transition of care
• Coordinate follow-up with PCPs, specialists, home health
• Educate patients and caregivers on self-management
• Document interactions in care management platform per guidelines

Responsibilities

• Post-discharge outreach within 24-72 hours to assess needs and gaps in care
• Coordinate follow-up appointments and post-acute services with providers and community resources
• Develop and implement individualized care plans for chronic conditions
• Educate members and caregivers using motivational interviewing techniques
• Document all interactions and interventions in the care management platform per policy

Skills

Care coordination

Post-discharge follow-up

Patient education

Motivational interviewing

Clinical documentation

Tools

Care management platform

Job description

“Sanitas is a global healthcare organization expanding across the United States. Our services include primary care, urgent care, nutrition, lab, diagnostic, health care education and resources for our patients. We strive to attract professionals who believe in our mission, vision and are dedicated to the service of our patients and their families creating a memorable experience through compassion, respect, and kindness.”

Job Summary

The Case Management RN manages the transition of care for members post-discharge and those with chronic conditions, coordinating follow-up care, creating personalized care plans, and educating patients and caregivers, to prevent hospital readmissions, reduce over-utilization, and improve overall health outcomes.

Essential Job Functions

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Conduct timely post-discharge outreach (within 24-72 hours), reviewing discharge summaries, medication lists, and follow-up recommendations, to assess member needs, confirm understanding of medical instructions, and identify immediate gaps in care.
• Coordinate follow-up appointments and post-acute services, collaborating with primary care providers, specialists, home health agencies, and community resources, to ensure seamless continuity of care across the continuum.
• Develop and implement individualized care plans based on assigned program categories, identifying early signs of complications or risk factors, to manage chronic conditions effectively and escalat[e] clinical issues appropriately.
• Educate members and caregivers using motivational interviewing techniques, providing guidance on red-flag symptoms and self-management strategies, to empower patients and reduce patterns of over-utilization (e.g., frequent ED visits).
• Document all interactions, assessments, and clinical interventions in the care management platform accurately and timely, to maintain compliance with organizational policies, advocate for member needs, and ensure alignment with clinical guidelines.