Clinical Care Coordinator - Transitions of Care (62070)

Sanitas • Leon Valley, TX

6d

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. Foreign physicians/Nurses are encourage to apply

Requirements

• High school graduate or equivalent.
• Certified Medical Assistant
• Foreign Physician / Nurse
• 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
• English: Advanced
• Required to visit the assigned centers, further emphasizing their commitment to maintaining a unified and patient-centric approach across various locations.

Nice To Haves

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

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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED
• Number of Employees: 5,001-10,000 employees