Transitions of Care Coordinator Medical Assistant

Penobscot Community Health Care•Bangor, ME

8d•$44,720 - $63,877

About The Position

The Transitions of Care Coordinator Medical Assistant helps patients transition safely from hospital or facility care to home and back to their primary care team. The role works with discharge teams, patients, primary care teams, and community partners to coordinate timely follow-up, identify barriers, and connect patients with needed resources. Responsibilities combine clinical services, patient outreach, and care coordination. The position includes reviewing discharges, screening and scheduling follow-up visits, documenting outreach and patient information in the electronic medical record, identifying urgent concerns and barriers, and collaborating with care teams and community partners. Clinical tasks may include vital signs, lab draws, vaccines, and point-of-care testing. Hospital rounds and home visits may be needed. The position is full-time, Monday through Friday, 8:00 a.m. to 4:30 p.m. It is based in a Designated Healthcare Facility subject to Maine immunization requirements. If hired, the employee must provide a Certificate of Immunization or Proof of Immunity for measles, mumps, rubella, varicella, hepatitis B, and influenza.

Requirements

High school diploma or equivalent.
Minimum of three years’ experience in primary healthcare.
Certification as an MA, CMA, RMA, or CCMA.
Current Healthcare Provider Basic Life Support training and certification issued by the American Heart Association, American Red Cross, or American Health & Safety Institute; must obtain it within two weeks if not current at hire.
Valid driver’s license with an acceptable driving record and/or appropriate length of driving experience for insurance purposes.
If hired, provide a Certificate of Immunization or Proof of Immunity for measles, mumps, rubella, varicella, hepatitis B, and influenza.

Nice To Haves

Relevant post-secondary education.
Previous experience with electronic medical records.
Care or case management experience.

Responsibilities

Review hospital and facility discharges, communicate with discharging teams, and coordinate timely follow-up appointments.
Apply payer requirements and PCHC criteria to determine Transitional Care Management (TCM) eligibility, document screening results, and schedule eligible patients for TCM visits or others for hospital follow-up visits; keep scheduling moving while eligibility screening is pending.
Contact patients after discharge; document outreach attempts and outcomes; maintain accurate patient cases and electronic medical record documentation; and route follow-up needs to the appropriate team.
Review risk information, recognize urgent clinical concerns and barriers to care, and collaborate with care teams to prioritize patients and coordinate follow-up.
Perform clinical services within scope of practice, which may include vital signs, lab draws, vaccines, and point-of-care testing.
Participate in hospital rounds and conduct home visits as needed.
Help patients access needed supplies, equipment, and other resources based on social drivers of health needs.
Collaborate with Care Management, the Community Care Team, Community Health Workers, and other partners to address social drivers of health, coordinate referrals, and support continuity of care beyond the initial transition period.
Collaborate with Transitions of Care and Care Management teams, provide coverage as needed, respond to partner inquiries, contribute to program data and reporting, and identify opportunities to improve workflows and patient outcomes.