CMA Transitional Care Coordinator
Job description
About the role
The Certified Medical Assistant serves as a Transitional Care Coordinator within partnered long-term care facilities in Waco, Texas. This role requires reliability, self-motivation, vigilance, and compassion in all patient interactions. The hire will work on-site as part of the clinical care team, focusing on transitional care management and attentive patient monitoring. They will build relationships with residents and their families over time to support continuity of care. The position involves close collaboration with providers to help patients stay healthy and avoid unnecessary hospitalizations. The role emphasizes maintaining patient presence in their home environment when it aligns with their care goals.
Key facts
What you'll do
Coordinate care for patients residing in skilled nursing and rehabilitation facilities using Ennoble Care's EMR system.
Facilitate transitional care management by ensuring services with the Housecalls division are initiated immediately upon a patient's discharge from the hospital.
Expedite time to first provider visit for newly transitioned patients in accordance with established clinical guidelines and protocols.
Monitor patients attentively throughout the day and communicate changes in condition promptly to the provider.
Initiate appropriate interventions and escalate care when clinically indicated, including activities billable under CCM codes.
Consistently support care coordination efforts to reduce avoidable emergency department visits and hospital readmissions for enrolled patients.
Collaborate daily with providers and facility staff to verify that care plans remain current and are actively implemented.
Utilize the Point Click Care EMR system for accurate clinical documentation and care coordination tasks.
Maintain strong communication with families, residents, facility staff, and the Housecalls division to keep all parties informed about care status.
Support the overall mission of providing high-quality, patient-centered care in long-term care settings across multiple locations.
Promote patient safety by identifying clinical concerns early and ensuring timely follow-up with the healthcare team.
Assist in the collection and reporting of care metrics as required for quality improvement and regulatory compliance.
Participate in ongoing training and team meetings to stay current with clinical best practices and organizational policies.
Contribute to a positive team environment through professional interactions and support of colleagues.
Requirements
Legally authorized to work in the United States of America.
Active, unrestricted Certified Medical Assistant license in the state of Texas.
Minimum 1 year of patient-facing experience in a long-term care, skilled nursing, or transitional care setting.
Comfortable communicating proactively throughout the day in person, by phone, via email, and through Microsoft Teams.
Solid working knowledge of healthcare terminology and care coordination principles.
Strong clinical assessment skills with the ability to identify and escalate changes in condition effectively.
Experience with EMR systems and clinical documentation; Point Click Care experience preferred.
Proficient use of Microsoft 365 including Excel, Outlook, Word, and Teams.
Excellent communication and interpersonal skills, with a strong foundation in organization, time management, and clinical documentation.
Capacity to work independently while collaborating closely with multidisciplinary teams.
Ability to work full-time in an on-site role 5 days per week based in the Waco, Texas area.
Daytime hours, approximately 8:00 a.m. to 5:00 p.m. Central Standard Time.
No evenings, no overnight shifts, and no on-call requirements.
Seven company-paid holidays annually.
Valid, unencumbered driver's license.
Reliable personally-owned vehicle suitable for travel between facilities when necessary.
Current auto insurance with proof of coverage available.
Ability to pass a standard background check.
Nice to have
Only items specified in the SOURCE are included under requirements; no additional preferred qualifications are listed.
Practical notes
The role requires full-time on-site presence in Waco, Texas, with daytime hours from approximately 8:00 a.m. to 5:00 p.m. CST. There are no evening shifts, overnight shifts, or on-call responsibilities. The position includes seven company-paid holidays annually. Travel between partnered facilities may be required as part of the transitional care coordination responsibilities.