Post-Discharge Care Navigator

RiseMe; Boca Raton (FL); On-site; USD 42,000 - 65,000; Full time

Job summary

Sanitas is seeking a Case Management Coordinator to oversee post-discharge transitions and chronic care management. You will coordinate follow-up services across primary care, specialists, and home health, and develop personalized care plans to improve outcomes.

The role requires MA certification, strong clinical knowledge, and experience in care coordination. Excellent communication and documentation skills are essential for accurate EMR entries and patient education.

Qualifications

• Must have clinical case management experience.
• Active MA national certification.
• Bilingual (English/Spanish) preferred.

Responsibilities

• Perform timely post-discharge outreach within 24-72 hours by reviewing discharge summaries and medication lists to assess needs and gaps in care.
• Coordinate follow-up appointments and post-acute services with PCPs, specialists, home health, and community resources.
• Develop individualized care plans based on program categories and identify early signs of complications or risk factors.
• Educate patients and caregivers using motivational interviewing and self-management guidance.
• Document all interactions and interventions accurately in the care management platform to ensure compliance.

Skills

Motivational interviewing

Care coordination

Post-discharge

Documentation

EMR documentation

Chronic disease management

Clinical knowledge

Communication

Problem-solving

Bilingual

Education

MA program graduate

High school diploma

Tools

EMR systems

Care management platforms

Job description

Sanitas is seeking a Case Management Coordinator to oversee post-discharge transitions and chronic care management. You will coordinate follow-up services across primary care, specialists, and home health, and develop personalized care plans to improve outcomes.

The role requires MA certification, strong clinical knowledge, and experience in care coordination. Excellent communication and documentation skills are essential for accurate EMR entries and patient education.