CMA Transitional Care Coordinator (Prince Georges County, MD)
Ennoble Care
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Job summary
Ennoble Care is seeking a full-time Certified Medical Assistant to serve as a Transitional Care Coordinator in Prince George's County, MD. The CMA will work on-site in partnered facilities, coordinating care, monitoring patients, and bridging communication between residents, families, and clinical teams.
The role emphasizes transitional care management, timely visits, and accurate documentation within Ennoble Care’s EMR.
Qualifications
- Active, unrestricted CMA license in Maryland
- Minimum 1 year of patient-facing experience in long-term care/rehabilitation settings
- Proven communication skills across in-person, phone, email, and Teams
- Experience with EMR systems and clinical documentation; PCC preferred
- Strong clinical assessment and ability to identify changes in condition
- Pass background check and driver's license with vehicle
- Ability to work full-time on-site in Prince George's County, MD, weekdays
Responsibilities
- Coordinate care for residents in skilled nursing facilities
- Facilitate transitional care management with hospital discharge processes
- Monitor patients and communicate condition changes to providers
- Support care plans with facility staff and family communication
- Document interactions accurately in the EMR
- Mentor new coordinators and promote best practices
- Maintain daily on-site presence and build relationships with residents
- Assist with chart reconciliation between Ennoble and facility records
Skills
Education
Tools
Job description
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. Ennoble Care’s clinicians go to the home of the patient, providing continuum of care for those with chronic conditions and limited mobility. Ennoble Care offers a variety of programs including, remote patient monitoring, behavioral health management, and chronic care management, to ensure that 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.” Join Ennoble Care today!
Ennoble Care is seeking a full-time Certified Medical Assistant to serve as aTransitional Care Coordinator within one or more of our partnered long-term care facilities in Prince George's County, Maryland. The right person for this role is reliable, self-motivated, vigilant, and compassionate. This is an integral, on-site role as part of our clinical care team, working closely alongside our providers in a family-practice-style model built around continuity, relationship-building, and patient-centered support.
You’ll get to know the residents (and their families) over time, monitor for changes in condition, and play a meaningful, hands-on role in helping people stay healthy, avoid unnecessary hospitalizations, and remain in their home -- where many of them want to be.
We’re proud of the culture we’ve built at Ennoble Care -- one that is positive, respectful, and rooted in genuine teamwork. People here are valued, supported in doing work that matters, and encouraged to maintain a healthy work-life balance. We invest in our team's growth through internal advancement opportunities based on performance, organizational needs, and role availability, because we believe that when our team thrives, so do our patients.
At Ennoble Care, our mission is simple: To care is an honor. For our patients, that means we come to you, we care for you, and we're here for you -- and that belief is at the heart of everything we do. As a CMA Transitional Care Coordinator, you'll bring that mission to life -- working on-site within one or more of our partnered skilled nursing and rehabilitation facilities in Prince George's County, Maryland. Your focus will be transitional care management, attentive patient monitoring, and day-to-day collaboration with our clinical team and facility staff -- serving as a reliable communication bridge among residents, families, facility staff, and our Housecalls division -- keeping everyone informed and care on track.
- Legally authorized to work in the United States of America
- Active, unrestricted CMA license in the state of Maryland
- 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 escalat changes in condition
- Experience with EMR systems and clinical documentation; Point Click Care experience preferred
- Proficient with Microsoft 365 including Excel, Outlook, Word, and Teams
- Excellent communication and interpersonal skills, with a solid foundationin 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 (days of week are flexible, weekends preferred) based in the Prince George's County, Maryland area.
- Daytime hours, approximately8:00 a.m. to 4:30 p.m. EST
- No evenings
- No over-night shifts
- No on-call requirements
- Seven (7) company-paid holidays annually
- Daytime hours, approximately8:00 a.m. to 4:30 p.m. EST
- Ability to pass background check
- Transportation criteria:
- Valid, unencumbered driver's license
- Reliable personally-owned vehicle
- Current auto insurance, with the ability to provide proof
Please note, travel between facilities may be required
- Coordinate care for patients residing in skilled nursing and rehabilitation facilities using Ennoble Care's EMR
- Facilitate transitional care management, 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 guidelines
- Monitor patients attentively, communicate changes in condition promptly to the provider, initiate appropriate interventions, and elevate care as clinically indicated, including CCM-billable activities
- Consistently support care coordination efforts to reduce avoidable emergency department visits and hospital readmissions
- Collaborate daily with providers and facility staff to ensure care plans are kept current and acted on
- Maintain a consistent and reliable daily on-site presence in assigned facilities
- Build ongoing relationships with residents and their families, maintaining a consistent presence that reinforces trust and continuity of care over time
- 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
- Serve as a key liaison between Ennoble Care providers, facility staff, residents, families, and the Housecalls team
- Collaborate closely with Ennoble Care providers within the skilled nursing or long-term care setting
- Provide timely, accurate clinical updates to providers to support informed decision-making
- Ability to convert two (2) eligible patients per day to Ennoble Care's Housecalls program
- Serve as a steady communication bridge between residents, families, the facility team, and our Housecalls division
- Function as a reliable communication bridge to ensure accurate, timely exchange of clinical information
Accurately document patient interactions, assessments, and care coordination activities in Ennoble Care’s EMR
Perform chart reconciliation to ensure accuracy and continuity of clinical records between Ennoble and facility records
Follow established workflows, documentation standards, and escalation protocols
- Support onboarding and training of new Transitional Care Coordinators
- Serve as a clinical mentor and resource for newly hired coordinators
- Promote best practices in transitional care, communication, and facility-based care coordination
- Contribute positively to team collaboration and foster strong partnerships with facility staff
- Embedded, on-site role within assigned skilled nursing and/or rehabilitation facilities
- Requires consistent daily presence and strong relationship-building with facility staff
- Fast-paced, patient-facing role requiring clinical judgment, adaptability, and proactive engagement
Patient-centered care
Clinical judgment and escalation
Care coordination and continuity
Communication and collaboration
Documentation accuracy and compliance
Relationship-building and teamwork
- Starting pay rate is $18.00-$19.00 hourly
- Quarterly bonus opportunities based on performance
- Mileage reimbursement eligibility when traveling between facilities
- Full-time health benefits eligibility, including a range of supplemental insurance options and elective benefits
- Medical, Dental, Vision and supplementary benefits such as Life Insurance, Short Term and Long Term Disability, Flexible Spending Accounts for Medical and Dependent Care, Accident, Critical Illness, and Hospital Indemnity.
- Paid Time Off
- Paid Office Holidays
- Paid Sick Time
- 401(k) with up to 3% company match
- Referral Program
- Payactiv: pay-on-demand. Cash out earned money when and where you need it!
Candidates must disclose any current or future need for employment-based immigration sponsorship (including, but not limited to - OPT, STEM OPT, or visa sponsorship) before an offer of employment is extended.
Ennoble Care is an Equal Opportunity Employer, committed to hiring the best team possible, and does not discriminate against protected characteristics including but not limited to - race, age, sexual orientation, gender identity and expression, national origin, religion, disability, and veteran status.
For government reporting purposes, we ask candidates to respond to the below self-identification survey.Completion of the form is entirely voluntary. Whatever your decision, it will not be considered in the hiringprocess or thereafter. Any information that you do provide will be recorded and maintained in aconfidential file.
As set forth in Ennoble Care’s Equal Employment Opportunity policy,we do not discriminate on the basis of any protected group status under any applicable law.
A "disabled veteran" is one of the following: a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a person who was discharged or released from active duty because of a service-connected disability.
A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
An "Armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.
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