What are the responsibilities and job description for the Case Management Coordinator - Transitions of Care position at Sanitas?
Job Details
Description
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
Qualifications
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.
While performing the duties of this job the employee is regularly required to work standing up, walk, use hands to operate tools and equipment and must be able to exert regularly up to 10 pounds of force, frequently exert 30 pounds of force and occasionally exert 50 pounds of force to constantly perform the essential job functions. The employee will be frequently required to reach with hands and arms, bend, balance, kneel, crouch, crawl, push, and pull. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus.
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