About The Position

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.

Requirements

  • 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
  • Medical Assistant License
  • 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

Nice To Haves

  • Knowledge of managed care and value-based care models.
  • Experience working with vulnerable or high-risk patient populations.

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.
© 2026 Teal Labs, Inc
Privacy PolicyTerms of Service