Advanced Medical Assistant - Chronic Care Management / Bilingual English-Spanish (68128) at Sanitas Medical Centers in Naples - Collier Blvd / Golden Gate / Organge Tree - Naples, FL 34119; Naples - North / Pelican Bay / Park Shore - Naples, FL 34109

Job description

• Position Type
• Full Time
• Job Shift
• On Site
• Travel Percentage
• None
• “Sanitas is a global healthcare organization expanding across the United States. Our services include primary care, urgent care, nutrition, lab, diagnostic, health care education and resources for our patients. We strive to attract professionals who believe in our mission, vision and are dedicated to the service of our patients and their families creating a memorable experience through compassion, respect, and kindness.”
• The Case Management Coordinator manages the transition of care for members post-discharge and those with chronic conditions, coordinating follow-up care, creating personalized care plans, and educating patients and caregivers, to prevent hospital readmissions, reduce over-utilization, and improve overall health outcomes.

Responsibilities

• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Conduct timely post-discharge outreach (within 24-72 hours), reviewing discharge summaries, medication lists, and follow-up recommendations, to assess member needs, confirm understanding of medical instructions, and identify immediate gaps in care.
• Coordinate follow-up appointments and post-acute services, collaborating with primary care providers, specialists, home health agencies, and community resources, to ensure seamless continuity of care across the continuum.
• Develop and implement individualized care plans based on assigned program categories, identifying early signs of complications or risk factors, to manage chronic conditions effectively and escalate clinical issues appropriately.
• Educate members and caregivers using motivational interviewing techniques, providing guidance on red-flag symptoms and self-management strategies, to empower patients and reduce patterns of over-utilization (e.g., frequent ED visits).
• Document all interactions, assessments, and clinical interventions in the care management platform accurately and timely, to maintain compliance with organizational policies, advocate for member needs, and ensure alignment with clinical guidelines.

Requirements

• This position currently has no supervisory responsibilities
• Required Education
• High school diploma or equivalent.
• Graduation from a nationally accredited Medical Assistant (MA) program
• Required Experience
• Proven experience in clinical case management, care coordination, utilization review, or population health management within a healthcare setting.
• Required Licenses and Certifications
• Active MA national certification.
• CPR/BLS for Healthcare Providers is required.
• Required Knowledge, Skills, and Abilities
• Clinical Knowledge: Strong, demonstrated understanding of chronic disease management, evidence-based medical guidelines, and post-acute care processes.
• Patient Engagement: Proficiency in motivational interviewing techniques to effectively educate and empower members and their caregivers.
• Communication: Excellent verbal and written communication skills to interact effectively with patients, interdisciplinary care teams, and community partners.
• Problem-Solving: Strong critical thinking and clinical problem-solving skills to identify barriers to care, risk factors for readmission, and appropriate transition plans.
• Technical Skills: Ability to accurately and timely document assessments and interventions in care management platforms or Electronic Medical Records (EMR).
• Certified Case Manager (CCM) credential or similar certification in care coordination/utilization review.
• Bilingual (English and Spanish) to effectively serve diverse member populations.

Skills

Required

• Active MA national certification.
• Advanced English is required.

Preferred

• Bilingual Spanish/Creole is preferred.