CMA Transitional Care Coordinator (Prince Georges County, MD)

Ennoble Care•Prince Georges County, MD, MD

2d•$18 - $19•Onsite

About The Position

Ennoble Care is seeking a full-time Certified Medical Assistant to work as a Transitional Care Coordinator at one or more partnered skilled nursing and rehabilitation facilities in Prince George's County, Maryland. This is an on-site, patient-facing role on Ennoble Care’s clinical team, working closely with providers and facility staff in a continuity-focused, patient-centered model. The coordinator supports transitional care management, monitors residents for changes in condition, and serves as a communication link among residents, families, facility staff, Ennoble Care providers, and the Housecalls division. The role aims to keep care plans current, support continuity of care, and help patients remain healthy while reducing avoidable hospitalizations. The position requires a consistent on-site presence five days per week, with flexible days and weekends preferred. Hours are approximately 8:00 a.m. to 4:30 p.m. Eastern Time; there are no evening, overnight, or on-call requirements. Travel between facilities may be required.

Requirements

Legally authorized to work in the United States.
Active, unrestricted Certified Medical Assistant license in Maryland.
At least one year of patient-facing experience in a long-term care, skilled nursing, or transitional care setting.
Comfort communicating proactively throughout the day in person, by phone, email, and Microsoft Teams.
Working knowledge of healthcare terminology and care coordination principles.
Strong clinical assessment skills and ability to identify and escalate changes in condition.
Experience with EMR systems and clinical documentation.
Proficiency with Microsoft 365, including Excel, Outlook, Word, and Teams.
Excellent communication and interpersonal skills, organization, time management, and clinical documentation skills.
Ability to work independently while collaborating closely with multidisciplinary teams.
Ability to work full-time on-site five days per week in the Prince George's County, Maryland area; days are flexible, with weekends preferred.
Ability to work daytime hours, approximately 8:00 a.m. to 4:30 p.m. Eastern Time; no evenings, overnight shifts, or on-call requirements.
Ability to pass a background check.
Valid, unencumbered driver's license, reliable personally owned vehicle, and current auto insurance with proof available.
Ability to travel between facilities as required.

Nice To Haves

Point Click Care experience.

Responsibilities

Coordinate care for patients residing in skilled nursing and rehabilitation facilities using Ennoble Care's EMR.
Facilitate transitional care management and ensure Housecalls services are initiated immediately after a patient's hospital discharge.
Expedite the first provider visit for newly transitioned patients in accordance with established guidelines.
Monitor patients and promptly communicate changes in condition to providers, initiate appropriate interventions, and escalate care as clinically indicated, including CCM-billable activities.
Support care coordination efforts to reduce avoidable emergency department visits and hospital readmissions.
Collaborate daily with providers and facility staff to keep care plans current and ensure they are acted on.
Maintain a consistent daily on-site presence in assigned facilities.
Build ongoing relationships with residents and their families to reinforce trust and continuity of care.
Collect routine and urgent vital signs as needed and conduct regular patient check-ins to support care plans, follow-ups, and clinical stability.
Identify changes in patient condition and promptly communicate concerns to the clinical team.
Serve as a liaison among Ennoble Care providers, facility staff, residents, families, and the Housecalls team, ensuring timely and accurate clinical information exchange.
Collaborate closely with Ennoble Care providers in skilled nursing and long-term care settings and provide timely clinical updates to support decision-making.
Convert two eligible patients per day to Ennoble Care's Housecalls program.
Accurately document patient interactions, assessments, and care coordination activities in Ennoble Care's EMR.
Reconcile charts to ensure accurate and continuous clinical records between Ennoble Care and facility records.
Follow established workflows, documentation standards, and escalation protocols.
Support onboarding and training of new Transitional Care Coordinators and serve as a clinical mentor and resource.
Promote best practices in transitional care, communication, and facility-based care coordination, and foster collaboration with facility staff.

Benefits

Quarterly bonus opportunities based on performance.
Mileage reimbursement eligibility when traveling between facilities.
Full-time health benefits eligibility, including medical, dental, vision, and supplemental insurance options.
Life insurance and short-term and long-term disability benefits.
Flexible Spending Accounts for medical and dependent care.
Accident, critical illness, and hospital indemnity benefits.
Paid Time Off.
Paid office holidays, including seven company-paid holidays annually.
Paid sick time.
401(k) with up to 3% company match.
Referral Program.
Payactiv pay-on-demand access to earned wages.