Case Management Coordinator - Transitions of Care

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

Required Licenses and Certifications

Medical Assistant License

Required Knowledge, Skills, and Abilities

Strong understanding of medical terminology and healthcare navigation.

Excellent verbal, written, and interpersonal communication skills.

Familiarity with social determinants of health and community resources.

Proficiency in EMR systems, Microsoft Office, and documentation practices.

Ability to work independently and in collaboration with interdisciplinary teams

Preferred Qualifications

Knowledge of managed care and value-based care models.

Experience working with vulnerable or high-risk patient populations.

Financial Responsibilities

None of the above - This position does not currenlty handle physical money or negotiate contracts

Budget Responsibilities

This position does not currently have Budget Responsibility

Languages

English: Advanced

Spanish: Preferred

Creole: Preferred

Travel

Required to visit the assigned centers, further emphasizing their commitment to maintaining a unified and patient-centric approach across various locations.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

Includes corporate and medical center administrative staff whose primary duties are office-based. These positions generally require prolonged sitting, computer use, occasional standing and walking, and the ability to lift or carry up to 20 pounds, with occasional travel between company locations as needed.

Environmental Conditions

Inside: The employee is subject to environmental conditions, protection from weather conditions but not necessarily from temperature changes. The worker is subject to noise; there may be sufficient noise to cause the worker to shout to be heard above ambient noise level.

Physical/Environmental Activities

Please indicate with an X the frequency for the activities that apply to the essential functions of the job based on the chart below. Please select Not Required for physical demands that aren’t essential to job performance.

Must be able to travel to multiple locations for work (i.e. travel to attend meetings, events, conferences). Not Required

May be exposed to outdoor weather conditions of cold, heat, wet, and humidity. Not Required

May be exposed to outdoor or warehouse conditions of loud. noises, vibration, fumes, dust, odors, and mists. Not Required

Must be able to ascend and descend ladders, stairs, or other equipment. Not Required

Subject to exposure to hazardous material. Not Required