Transitional Care Specialist (TCS)/Medical Assistant

DMC Primary Care • Bedford, NH

18d • Onsite

About The Position

DMC Primary Care seeks a Certified Medical Assistant for the full-time role of Transitional Care Specialist (TCS). A TCS is responsible for supporting patients as they transition from inpatient, emergency department, skilled nursing, or acute rehab settings back to the primary care environment. The TCS enhances patient outcomes by coordinating follow-up care, conducting structured post-discharge outreach, ensuring timely communication between care teams, and appropriately addressing clinical or social needs that may impact recovery. This role works closely with providers, nursing staff, care managers, and administrative teams to maintain continuity of care and reduce avoidable readmissions. Duties Include (but are not limited to): Conduct timely post-discharge outreach (phone calls, portal messages, or other approved outreach methods) to assess patient status, confirm discharge instructions, and identify clinical or social concerns. Review hospital or rehabilitation discharge summaries, identify required follow-up actions, and route information to the appropriate provider. Schedule transitional care management (TCM) visits within required timeframes and support patients in overcoming barriers to attending these appointments. Perform structured clinical assessments during outreach calls within CMA scope, including medication reconciliation, symptom check-ins, and identification of red-flag symptoms requiring escalation. Collaborate with primary care providers to ensure timely evaluation of complex cases and communicate urgent issues promptly. Coordinate with care management, behavioral health, social work, home care, and community resource programs to address identified patient needs. Track pending labs, imaging, referrals, or other follow-up items related to transitional care. Support quality improvement initiatives related to care transitions, readmission reduction, and chronic disease management. Participate in interdisciplinary care meetings and provide updates on transitional care caseloads. This is a full-time hourly position located in Bedford. The successful candidate will have the following qualifications:

Requirements

• High School Diploma (required)
• 3+ years’ experience working in a medical office or healthcare setting
• 2+ years working as a medical assistant

Nice To Haves

• Medical Assistant certification (preferred)

Responsibilities

• Conduct timely post-discharge outreach (phone calls, portal messages, or other approved outreach methods) to assess patient status, confirm discharge instructions, and identify clinical or social concerns.
• Review hospital or rehabilitation discharge summaries, identify required follow-up actions, and route information to the appropriate provider.
• Schedule transitional care management (TCM) visits within required timeframes and support patients in overcoming barriers to attending these appointments.
• Perform structured clinical assessments during outreach calls within CMA scope, including medication reconciliation, symptom check-ins, and identification of red-flag symptoms requiring escalation.
• Collaborate with primary care providers to ensure timely evaluation of complex cases and communicate urgent issues promptly.
• Coordinate with care management, behavioral health, social work, home care, and community resource programs to address identified patient needs.
• Track pending labs, imaging, referrals, or other follow-up items related to transitional care.
• Support quality improvement initiatives related to care transitions, readmission reduction, and chronic disease management.
• Participate in interdisciplinary care meetings and provide updates on transitional care caseloads.

Benefits

• Paid time off
• Competitive pay
• Comprehensive health, dental, prescription, and vision benefits
• Company-paid short-term disability, long-term disability and life insurance coverages
• 401k

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED
• Number of Employees: 101-250 employees