Job Description

The Onsite Inpatient Case Manager is responsible for being onsite at hospitals to coordinate and manage care transitions for patients following ED, hospitalization or skilled nursing facility stays. The Case Manager works onsite with clinical teams, providers, and community partners to ensure safe, timely, and effective care transitions that reduce readmissions, ED Diversion, and works to improve patient outcomes and experience.

Location- Sarasota or Lakewood Ranch

$500 Hiring bonus to be paid after 30 days of employment.

** Compensation Based on Experience and Qualifications***

Typical work hours are Monday - Friday 8:00am to 5:00 pm with some flexibility.

Key Responsibilities

• Conduct face-to-face or bedside visits with attendings, patients and care team prior to discharge to assess needs, barriers, and risks.
• Develop and implement individualized transitional care plans in collaboration with providers, hospital discharge planners, and caregivers.
• Ensure timely post-discharge scheduling of follow-up appointments within 3 days as appropriate.
• Coordinate medication reconciliation and education with pharmacists or nursing staff.
• Identify and address social determinants of health impacting recovery or self-management.
• Monitor patient progress during the 30-day post-discharge period, providing outreach, coaching, and coordination as needed.
• Maintain documentation in the electronic health record (EHR) according to TCM and organizational standards.
• Track outcomes such as readmissions, ER visits, and follow-up adherence using population health tools.
• Serve as liaison between inpatient and outpatient care teams, ensuring effective communication and continuity of care.

Qualifications

• Education: RN, LPN, SW, or other licensed healthcare professional required.
• Experience: Minimum 3 years of clinical or case management experience; experience in care transitions, population health, or chronic disease management preferred.

Experience

• Three years in a professional setting such as hospital, clinic setting, or Managed Care Organization
• Experience related to case management, utilization management, quality assurance, discharge planning or other cost management program preferred
• Experience working with Medicare Advantage Population preferred

Knowledge, Skills and Abilities:

• Excellent organizational, time management, and prioritization skills
• Critical thinking skills, excellent problem solving, and good decision making abilities
• Demonstrate a professional appearance and demeanor with patients, providers and coworkers.
• Proficiency with computers, experience in basic office programs and EMR or EHR systems.

ABOUT MAXHEALTH

MaxHealth is dedicated to simplifying healthcare and ensuring healthier futures-for our patients and our people.

Founded in 2015, MaxHealth is a leading primary care platform focused on delivering high‑quality, integrated, value‑based care to adults and senior patients throughout Florida. Today, we support more than 70,000 value‑based care patients through a growing network of more than 55 owned clinics and 30 affiliated practices across central and southern Florida.

Our success is driven by our people. MaxHealth is home to a diverse, multidisciplinary team of more than 700 employees-including primary care providers, specialists, clinical staff, and corporate professionals-who are united by a shared purpose: to make healthcare simpler, more compassionate, and more human.

We are proud to offer a workplace that supports career growth, internal advancement, and work‑life balance, with regular weekday office hours and a strong commitment to employee well‑being.

At MaxHealth, team members are encouraged to grow their skills, pursue leadership opportunities, and build long‑term careers in an environment where their contributions truly matter.

MaxHealth also partners with like‑minded independent providers, leveraging our platform to expand access to high‑quality care while preserving the personalized relationships that define great medicine.

Our values guide everything we do: we are customer‑centered, compassionate, results‑driven, proactive, collaborative, and adaptable. These values shape not only how we care for patients, but how we support one another as colleagues.

Our mission is simple: to deliver quality care, a simplified experience, and happiness-one patient, and one team member, at a time.

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