CMA Transitional Care Coordinator; Prince Georges County, MD

Ennoble Care is a mobile primary care, palliative care, and hospice service provider with patients in New York, New Jersey, Maryland, DC, Virginia, Oklahoma, Kansas, Pennsylvania, Texas, Florida, and Georgia. Our clinicians go to the patient’s home to provide a continuum of care for those with chronic conditions and limited mobility. We offer a variety of programs, including remote patient monitoring, behavioral health management, and chronic care management, to ensure our patients receive the highest quality of care by a team they know and trust.

We seek individuals who are driven to make a difference and embody our motto, “To Care is an Honor.”

We are seeking a full‑time Certified Medical Assistant to serve as a Transitional Care Coordinator in Prince George’s County, Maryland. The role is on‑site within partnered long‑term care facilities. The right candidate will be reliable, self‑motivated, vigilant, and compassionate. You will monitor residents, provide hands‑on care, and help people stay healthy and avoid unnecessary hospitalizations.

• Legally authorized to work in the United States
• Active, unrestricted CMA license in Maryland
• Minimum one 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 elevate changes in condition
• Experience with EMR systems and clinical documentation;
  Point‑Click Care experience preferred
• Proficient with Microsoft 365 (Excel, Outlook, Word, Teams)
• Excellent communication and interpersonal skills with strong organization, time‑management, and documentation abilities
• Ability to work independently while collaborating closely with multidisciplinary teams
• Full‑time, on‑site availability: 5 days per week, weekdays with weekends preferred; daytime hours (approximately 8:00 a.m. to 4:30 p.m. EST). No evenings, overnight shifts, or on‑call requirements. Seven paid holidays per year.
• Ability to pass a background check and drug screen
• Valid, unencumbered driver’s license; reliable, personally owned vehicle; current auto insurance with proof available

Care Coordination & Transitional Care Management

• Coordinate care for patients residing in skilled nursing and rehabilitation facilities using Ennoble Care’s EMR.
• Facilitate transitional care management, ensuring services with the House calls 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 guidelines.
• Monitor patients attentive‑ly, communicate changes in condition promptly to the provider, initiate appropriate interventions, and elevate care as clinically indicated, including CCM‑billable activities.
• Support coordination efforts to reduce avoidable emergency department visits and hospital readmissions.
• Collaborate daily with providers and facility staff to ensure care plans are current and acted on.

On‑Site Clinical Support

• Maintain a consistent and reliable daily on‑site presence in assigned facilities.
• Build ongoing relationships with residents and their families, reinforcing trust and continuity of care.
• Conduct routine and urgent vital‑sign collection as needed.
• Perform 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.

Communication & Collaboration

• Serve as a liaison between Ennoble Care providers, facility staff, residents, families, and the House calls team.
• Provide timely, accurate clinical updates to providers to support informed decision‑making.
• Convert two eligible patients per day to Ennoble Care’s House calls program.

Documentation & EMR Management

• Accurately document patient interactions, assessments, and care‑coordination activities in Ennoble Care’s EMR.
• Perform chart reconciliation to ensure accuracy and continuity of…