Medical Assistant Care Coordinator – Assisted Living 360° Care Model

Position Summary

The Medical Assistant Care Coordinator is the on-site backbone of a comprehensive 360° geriatric care model within an assisted living community, orchestrating how residents move through and experience the full continuum of medical and supportive services. This role blends clinical support, care coordination, and high-touch relationship management to align the Nurse Practitioner (NP), assisted living staff, families, and Interim HealthCare programs into one cohesive, resident-centered care experience.

Embedded in the community, the Care Coordinator connects primary care with Home Health, Hospice, Palliative Care, Therapy, Staffing, and Private Duty services, helping ensure that each resident receives the right level of care at the right time while reducing gaps, delays, and fragmentation. The position requires strong professional communication, EMR proficiency (eClinicalWorks and Axxess), and a calm, consistent presence that residents, families, and staff can rely on throughout the day.

Schedule: Monday through Friday, 8:00 a.m. to 5:00 p.m.

Key Responsibilities

Care Coordination & Resident Support

• Serve as the primary on-site care coordination contact for residents, families, assisted living staff, the NP, and all applicable Interim HealthCare service lines.
• Coordinate and manage NP scheduling, visit logistics, and follow-up needs, including labs, diagnostics, and external physician appointments, without making independent clinical decisions.
• Receive and organize requests from assisted living staff and families (urgent vs. routine), routing them appropriately to the NP or relevant service line.
• Help identify residents who may benefit from Home Health, Hospice, Palliative Care, Therapy, Staffing, or Private Duty services based on observed changes, facility reports, or caregiver concerns, escalating to the NP or appropriate clinician for evaluation.
• Support timely transitions between levels of care and Interim business lines by coordinating non-clinical referral logistics (paperwork, communication, scheduling) once clinical decisions have been made.
• Manage and track follow-up on phone calls from the facility, residents, and families; ensure lab results, imaging, and test outcomes are routed, acknowledged, and acted upon by the appropriate clinician.

Clinical & Administrative Support (Within MA Scope, PRN)

• Provide limited, PRN clinical support within Medical Assistant scope of practice at the direction of the NP (for example, obtaining basic measurements or assisting during on-site NP visits as needed).
• Assist with specimen collection and processing for labs, when requested and within scope.
• Promptly escalate any observed or reported changes in resident condition, concerns, or urgent issues to the NP or designated clinician rather than independently assessing or treating.
• Maintain readiness of basic clinical supplies and portable equipment used by the NP and other Interim clinicians in the building.

EMR, Documentation & Tracking

• Document coordination activities, clinical support tasks, and communication accurately and timely in eClinicalWorks (eCW), Axxess, and the assisted living facility chart, following established standards.
• Help prepare charts, manage order entry workflows, and complete follow-up tasks related to labs, diagnostics, referrals, and service-line orders.
• Maintain basic tracking systems/logs for pending labs, diagnostics, referrals, prior authorizations, and service-line referrals to ensure closed-loop follow-up.
• Obtain and upload outside clinical records (hospital/SNF discharges, specialist notes) into the EMR or NP workflow, in accordance with privacy regulations.

Resident Engagement & Community Presence

• Maintain a consistent, visible, and professional presence within the assisted living community throughout scheduled work hours.
• Build rapport with residents and families; answer basic non-clinical questions and help them understand how to access NP services and Interim HealthCare programs.
• Direct all clinical questions, medical concerns, and treatment decisions to the NP or appropriate clinician.
• Serve as a positive, trusted representative of Interim HealthCare and the NP practice within the community.

Facility & Business-Line Liaison

• Act as the day-to-day on-site point of contact for assisted living leadership and staff for non-clinical questions related to NP visits and Interim visits (room use, visit timing, workflow coordination).
• Maintain awareness of Interim program offerings and basic eligibility indicators to appropriately route potential referrals to the NP or relevant service line, without determining medical necessity.
• Coordinate in-building visit logistics for Interim clinicians (Home Health, Hospice, Therapy, Private Duty, Staffing) to minimize disruption to resident routines and facility operations.
• Assist in the preparation and logistics for care conferences or family meetings (scheduling, assembling documents, organizing notes) at the direction of the NP or leadership.

Quality, Safety, and Compliance Support

• Perform all duties strictly within Medical Assistant scope of practice and under the direction of the NP and Medical Director.
• Adhere to HIPAA, infection control, and safety standards at all times; maintain confidentiality of resident, facility, and organizational information.
• Support basic data collection and tracking related to quality and safety (e.g., hospitalizations, falls seen by NP, vaccination lists) as directed.
• Promptly report safety issues, suspected abuse/neglect, or environmental hazards per policy.

• Demonstrate professionalism, effective communication, and collaboration with assisted living staff and Interim teams to support coordinated, resident-centered care.

Qualifications Required

• Certified or Registered Medical Assistant (CMA/RMA).
• Completion of an accredited Medical Assistant program.
• Current CPR/BLS certification.
• Current TB test or ability to obtain prior to start date.
• Meets background check and onboarding requirements per policy and state regulations.
• Comfortable working with the senior population in a relationship-based model.
• Strong communication, organization, and documentation skills.
• Comfortable using tablets, laptops, and mobile documentation tools; ability to learn and effectively use EMRs (eCW, Axxess).
• Ability to work independently while coordinating with a mobile provider and multiple service lines.

Preferred

• Experience in assisted living, long-term care, or geriatric-focused settings.
• Experience in care coordination, population health, or supporting Nurse Practitioners/primary care providers.
• Prior experience with eClinicalWorks, Axxess, or similar EMRs (training provided as needed).

Physical & Work Requirements

• Ability to walk throughout the assisted living community for most of the workday.
• Ability to enter resident apartments as needed for scheduled visits and coordination tasks.
• Ability to stand, sit, and move frequently throughout the building.
• Ability to lift and carry portable medical equipment up to 25 lbs.
• Position requires primary presence within the assisted living community; off-site travel is not routinely required and must be approved in advance.

Reporting Relationship

Reports directly to the Hospice and Palliative Care Medical Director for clinical oversight and practice standards. The role also has a dotted-line reporting relationship to the Vice President of Home Health and Hospice, the Vice President of Staffing, and applicable service line directors to support cross-functional clinical coordination and alignment across the care continuum. The Care Coordinator works in close daily collaboration with the on-site Nurse Practitioner, assisted living staff, and all Interim HealthCare service teams involved in resident care.

Role Flexibility & Employment Statements