CMA Transitional Care Coordinator (Waco, TX)

Ennoble Care is seeking a full-time Certified Medical Assistant to serve as a Transitional Care Coordinator within one or more of its partnered long-term care facilities in Waco, Texas. This is an integral, on-site role as part of the clinical care team, working closely alongside providers in a family-practice-style model built around continuity, relationship-building, and patient-centered support. The role focuses on transitional care management, attentive patient monitoring, and day-to-day collaboration with the clinical team and facility staff, serving as a communication bridge among residents, families, facility staff, and the Housecalls division.

Responsibilities

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 escalate 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; 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; 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; 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

Requirements

Legally authorized to work in the United States of America; Active, unrestricted CMA 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; Experience with EMR systems and clinical documentation; Proficient with Microsoft 365 including Excel, Outlook, Word, and Teams; Excellent communication and interpersonal skills, with a solid 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 in the Waco, Texas area; Daytime hours, approximately 8:00 a.m. to 5:00 p.m. CST; No evenings; No over-night shifts; No on-call requirements; Ability to pass background check; Valid, unencumbered driver's license; Reliable personally-owned vehicle; Current auto insurance, with the ability to provide proof

Nice to have

Point Click Care experience preferred

Benefits

Starting pay rate of $19.00 hourly + bonus; Quarterly bonus opportunities based on performance; Mileage reimbursement eligibility when traveling between facilities; Full-time health benefits eligibility; 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; Seven (7) company-paid holidays annually; Paid Sick Time; 401(k) with up to 3% company match; Referral Program; Payactiv pay-on-demand