Case Management Coordinator - Transitions of Care

About the role

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.

Responsibilities

• 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.

Requirements

• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Qualifications

• High school graduate or equivalent.
• 3–5 years of experience in a clinical or community health setting.
• Experience in care coordination, discharge planning, or case management.