Transitional Care Coordinator (Cleveland, OH)

Transitional Care Coordinator (Cleveland, OH)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 a Transitional Care Coordinator within one or more of our partnered long-term care facilities in Cleveland, Ohio. 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.About The RoleAt 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 Cleveland, Ohio. 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.Required QualificationsLegally authorized to work in the United States of AmericaActive, unrestricted CMA license in the state of TexasMinimum 1 year of patient-facing experience in a long-term care, skilled nursing or transitional care settingComfortable communicating proactively throughout the day in person, by phone, via email, and through Microsoft TeamsSolid working knowledge of healthcare terminology and care coordination principlesStrong clinical assessment skills with the ability to identify and escalate changes in conditionExperience with EMR systems and clinical documentation; Point Click Care experience preferredProficient with Microsoft 365 including Excel, Outlook, Word, and TeamsExcellent communication and interpersonal skills, with a solid foundation in organization, time management, and clinical documentationCapacity to work independently while collaborating closely with multidisciplinary teamsAbility to work full-time in an on-site role 5 days per week (days of week are flexible, weekends preferred) based in the Cleveland, Ohio area.Daytime hours, approximately 8:00 a.m. to 5:00 p.m. ESTNo eveningsNo over-night shiftsNo on-call requirementsSeven (7) company-paid holidays annuallyAbility to pass background checkTransportation criteria:Valid, unencumbered driver's licenseReliable personally-owned vehicleCurrent auto insurance, with the ability to provide proofPlease note, travel between facilities may be requiredKey ResponsibilitiesCare Coordination & Transitional Care ManagementCoordinate care for patients residing in skilled nursing and rehabilitation facilities using Ennoble Care's EMRFacilitate transitional care management, ensuring services with the Housecalls division are initiated immediately upon a patient's discharge from the hospitalExpedite time to first provider visit for newly transitioned patients in accordance with established guidelinesMonitor patients attentively, communicate changes in condition promptly to the provider, initiate appropriate interventions, and escalate care as clinically indicated, including CCM-billable activitiesConsistently support care coordination efforts to reduce avoidable emergency department visits and hospital readmissionsCollaborate daily with providers and facility staff to ensure care plans are kept current and acted onOn-Site Clinical SupportMaintain a consistent and reliable daily on-site presence in assigned facilitiesBuild ongoing relationships with residents and their families, maintaining a consistent presence that reinforces trust and continuity of care over timeConduct routine and urgent vital sign collection as neededPerform regular patient check-ins to support care plans, follow-ups, and clinical stabilityIdentify changes in patient condition and promptly communicate concerns to the clinical teamCommunication & CollaborationServe as a key liaison between Ennoble Care providers, facility staff, residents, families, and the Housecalls teamCollaborate closely with Ennoble Care providers within the skilled nursing or long-term care settingProvide timely, accurate clinical updates to providers to support informed decision-makingAbility to convert two (2) eligible patients per day to Ennoble Care's Housecalls programServe as a steady communication bridge between residents, families, the facility team, and our Housecalls divisionFunction as a reliable communication bridge to ensure accurate, timely exchange of clinical informationDocumentation & EMR ManagementAccurately document patient interactions, assessments, and care coordination activities in Ennoble Care's EMRPerform chart reconciliation to ensure accuracy and continuity of clinical records between Ennoble and facility recordsFollow established workflows, documentation standards, and escalation protocolsTeam Support & LeadershipSupport onboarding and training of new Transitional Care CoordinatorsServe as a clinical mentor and resource for newly hired coordinatorsPromote best practices in transitional care, communication, and facility-based care coordinationContribute positively to team collaboration and foster strong partnerships with facility staffWork Environment & ExpectationsEmbedded, on-site role within assigned skilled nursing and/or rehabilitation facilitiesRequires consistent daily presence and strong relationship-building with facility staffFast-paced, patient-facing role requiring clinical judgment, adaptability, and proactive engagementCore CompetenciesPatient-centered careClinical judgment and escalationCare coordination and continuityCommunication and collaborationDocumentation accuracy and complianceRelationship-building and teamworkCompensation & BenefitsStarting pay rate is $18.00-$19.00 hourlyQuarterly bonus opportunities based on performanceMileage reimbursement eligibility when traveling between facilitiesFull-time health benefits eligibility, including a range of supplemental insurance options and elective benefitsFull-time employees qualify for the following benefits:Medical, Dental, Vision and supplementary benefits Ennoble Care