CMA Transitional Care Coordinator (Waco, TX)

Ennoble Care • Waco, TX

2d • Onsite

About The Position

Ennoble Care is seeking a full-time Certified Medical Assistant to serve as a Transitional Care Coordinator at one or more partnered skilled nursing, rehabilitation, or long-term care facilities in Waco, Texas. This is an on-site role on Ennoble Care’s clinical team, focused on transitional care management, patient monitoring, and daily collaboration with providers and facility staff. The coordinator serves as a communication link among residents, families, facility staff, providers, and the Housecalls division, helping maintain continuity of care and support patients in remaining at home when possible.

The role involves building ongoing relationships with residents and families, monitoring changes in condition, coordinating care after hospital discharge, and documenting clinical interactions and care coordination in the EMR. The coordinator also supports onboarding and mentoring new Transitional Care Coordinators. The position is scheduled five days per week, with flexible days and weekends preferred, during daytime hours of approximately 8:00 a.m. to 5:00 p.m. CST. 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 (CMA) license in Texas.
• 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 with multidisciplinary teams.
• Ability to work full-time on-site five days per week in the Waco, Texas area; days are flexible, with weekends preferred.
• Ability to work daytime hours, approximately 8:00 a.m. to 5:00 p.m. CST; no evenings, overnight shifts, or on-call requirements.
• Ability to pass a background check.
• Valid, unencumbered driver’s license, a reliable personally owned vehicle, and current auto insurance with proof available.
• Ability to travel between facilities if required.

Nice To Haves

• PointClickCare 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, 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 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 between Ennoble Care providers, facility staff, residents, families, and the Housecalls team.
• Provide timely, accurate clinical updates to providers to support informed 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 maintain accuracy and continuity 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 strong partnerships with facility staff.

Benefits

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

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: No Education Listed