Transitional Care Specialist; TCS​/Medical Assistant

Overview

Are you an experienced Medical Assistant who is ready to join a great team? 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.

• 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 time frames 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.

Full time position located in Bedford.

Education and Training: High School Diploma (required)

Experience:

• 3+ years’ experience working in a medical office or healthcare setting
• 2+ years working as a medical assistant

License & Certification: Medical Assistant certification (preferred)

• 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

DMC Primary Care, a physician-owned, independent practice, has been providing comprehensive care for families since 1964. Our offices are located in Bedford, Concord, Derry, Dover, Goffstown, Londonderry, Raymond, and Windham, New Hampshire. For more information, visit

We are an equal opportunity employer embracing the strength that diversity brings to the workplace. We provide a welcoming and supportive environment for employees of all ethnic backgrounds, cultures, ages, lifestyles and physical abilities.