Post-Discharge Care & Chronic Conditions Coordinator

Sanitas Medical Centers; Boca Raton (FL); On-site; USD 52,000 - 74,000; Full time

Job summary

Sanitas Medical Centers is seeking a Case Management Coordinator in Boca Raton, FL. This role focuses on coordinating transitions of care for discharged patients and those with chronic conditions to improve health outcomes and reduce readmissions.

You will develop personalized care plans, educate patients, and collaborate with caregivers and clinicians across the care continuum. The position emphasizes proactive outreach, interprofessional communication, and accurate documentation in our

Responsibilities

• Conduct timely post-discharge outreach within 24-72 hours to assess member needs, confirm understanding of medical instructions, and identify immediate gaps in care.
• Coordinate follow-up appointments and post-acute services with primary care providers, specialists, home health agencies, and community resources for seamless continuity of care.
• Develop and implement individualized care plans based on assigned program categories, identifying early signs of complications or risk factors and escalating clinical issues as needed.
• Educate members and caregivers using motivational interviewing, providing guidance on red-flag symptoms and self-management strategies to reduce over-utilization.
• Document all interactions, assessments, and interventions in the care management platform to maintain compliance and align with clinical guidelines.

Job description

Sanitas Medical Centers is seeking a Case Management Coordinator in Boca Raton, FL. This role focuses on coordinating transitions of care for discharged patients and those with chronic conditions to improve health outcomes and reduce readmissions.

You will develop personalized care plans, educate patients, and collaborate with caregivers and clinicians across the care continuum. The position emphasizes proactive outreach, interprofessional communication, and accurate documentation in our