Case Management Coordinator - Inpatient

About the role

Case Management Coordinator – Inpatient facilitates the transition of patients from inpatient facilities to the appropriate level of care by coordinating discharge planning, arranging follow-up, and addressing barriers to care. This role plays a critical function in reducing avoidable readmissions and supporting Sanitas’ value-based care strategy by ensuring smooth, patient-centered care transitions and strong alignment with providers and payor partners.

Responsibilities

• Initiate discharge planning upon notification of patient admission.
• Engage patients at inpatient or post-acute facilities and assess discharge readiness.
• Collaborate with Hospitalists, discharge planners, and payer care teams to develop discharge plans.
• Coordinate timely follow-up appointments with PCPs and specialists per discharge instructions.
• Educate patients and families about care instructions, resources, and home-based options.
• Identify and address barriers to safe discharge, including transportation and social needs.
• Document interactions, plans, and care coordination activities in the EMR.
• Monitor and report patient outcomes and care effectiveness to interdisciplinary teams.
• Facilitate communication between providers, facilities, and community-based organizations.
• Contribute to process improvement initiatives related to care transitions.