Advanced Medical Assistant - Chronic Care Management / Bilingual English - Spanish (69877)

Job Summary

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.

Essential Job Functions

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

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.

Supervisory Responsibilities

This position has no supervisory responsibilities

Required Education

High school graduate or equivalent.

Required Experience

3 - 5 years of experience in clinical, case management, or community health settings.

Experience in inpatient discharge planning or care coordination.