Post-Discharge Care Navigator

Sanitas Medical Centers; Katy (TX); On-site; USD 58,000 - 78,000; Full time

Job summary

Sanitas Medical Centers in Katy, TX, is seeking a Case Management Coordinator to oversee transition of care for members post-discharge and those with chronic conditions. You will coordinate follow-up care, create personalized care plans, and educate patients and caregivers to prevent readmissions.

You will collaborate with primary care providers, specialists, home health agencies, and community resources to ensure seamless continuity of care.

Qualifications

• Experience in care coordination and transition of care.
• Ability to coordinate with multiple care providers and services.
• Strong communication and patient education skills.
• Proficiency with motivational interviewing techniques.
• Experience documenting in care management systems.

Responsibilities

• Conduct timely post-discharge outreach (within 24-72 hours) to assess member needs and identify gaps in care.
• Coordinate follow-up appointments and post-acute services with providers and home health agencies to ensure continuity.
• Develop individualized care plans and identify early signs of complications to manage chronic conditions.
• Educate members and caregivers using motivational interviewing to reduce unnecessary utilization.
• Document interactions and interventions in the care management platform to ensure compliance and advocacy.

Skills

Care coordination

Discharge planning

Motivational interviewing

Patient education

Documentation

Tools

Care management platform

Job description

Sanitas Medical Centers in Katy, TX, is seeking a Case Management Coordinator to oversee transition of care for members post-discharge and those with chronic conditions. You will coordinate follow-up care, create personalized care plans, and educate patients and caregivers to prevent readmissions.

You will collaborate with primary care providers, specialists, home health agencies, and community resources to ensure seamless continuity of care.