Transitions of Care Coordinator Medical Assistant

Help patients navigate the transition from hospital to home and back to their primary care team. As a Transitions Coordinator Medical Assistant, you’ll help ensure patients receive timely follow-up, understand their next steps, and have the support they need to recover safely.

You’ll work closely with hospital discharge teams, patients, primary care teams, and community partners to coordinate follow-up care, identify potential barriers, and connect patients with the right resources. This role combines clinical skills, patient outreach, and care coordination to help make transitions safer and more seamless.

This position works in a Designated Healthcare Facility which is subject to the State of Maine’s immunization requirements for healthcare workers. If hired, you will be required to show a Certificate of Immunization, or Proof of Immunity, against: 1.) Rubeola (measles); Mumps; Rubella (German measles); Varicella; Hepatitis B; and Influenza.

Schedule: Full-Time, Monday-Friday, 8am-4:30pm

WHAT YOU’LL DO

• Coordinate transitions of care: Review hospital and facility discharges, communicate with discharging teams, and coordinate timely follow-up appointments to support continuity of care.
• Screen and schedule follow-up care: Apply payer requirements and PCHC criteria to determine Transitional Care Management (TCM) eligibility, document screening results, and schedule eligible patients for TCM visits and others for hospital follow-up visits. Keep scheduling moving while eligibility screening is pending.
• Conduct patient outreach and document follow-up: Contact patients after discharge, document outreach attempts and outcomes, maintain accurate patient cases and electronic medical record (EMR) documentation, and route follow-up needs to the appropriate team.
• Identify and address patient needs: Review risk information, recognize urgent clinical concerns and barriers to care, and collaborate with care teams to prioritize patients and coordinate appropriate follow-up.
• Provide clinical and community-based support: Perform clinical services within scope of practice, which may include vital signs, lab draws, vaccines, and point-of-care testing. Participate in hospital rounds and conduct home visits as needed, and help patients access needed supplies, equipment, and other resources as identified by social driver of health needs.
• Connect patients with ongoing care and resources: Collaborate with Care Management, the Community Care Team (CCT), Community Health Workers (CHWs), and other partners to address social drivers of health, coordinate referrals, and support continuity of care beyond the initial transition period.
• Support team operations and improvement: Collaborate with the Transitions of Care and Care Management teams, provide coverage as needed, respond to partner inquiries, contribute to program data and reporting, and identify opportunities to improve workflows and patient outcomes.

Join PCHC's nationally recognized non-profit organization:

• Federally Qualified Health Center offering integrated Medical Home Model
• Collegial professional atmosphere with informed leadership
• Flexible schedules supportive of work/life balance
• Competitive compensation and generous benefits
• PCHC cares for the WHOLE person, offering a broad range of integrated services, including Psychiatry & Mental Health, Dental, Family Medicine, Pediatrics, Pharmacy, Geriatrics, Laboratory Services, Physical Therapy, and more!

Education and Experience:

• High School Diploma (or equivalent) required. Relevant post-secondary education preferred.
• Minimum of three years’ experience in primary healthcare required.
• Certification as an MA, CMA, RMA, CCMA required.
• Previous experience with electronic medical record preferred.
• Care/Case Management experience preferred.
• Will have up-to-date training and certification in Healthcare Provider Basic Life Support issued by American Heart Association, American Red Cross, or American Health & Safety Institute. Must obtain within 2 weeks if not current at hire.
• Having a valid driver’s license with an acceptable driving record and/or an appropriate length of driving experience for insurance purposes is required. Any concerns raised by the results of a driving record check will be subject to an individualized review to determine whether the infraction is relevant to the individual’s ability to perform the responsibilities of the position in accordance with PCHC’s Automobile Safety and Background Check Policy.

Ready to Join Us?

If you’re curious, excited, or just want to learn more—we’d love to hear from you!
Apply today, or request the full job description by emailing recruitment@pchc.com (mailto:recruitment@pchc.com).

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, or any other characteristic protected by law.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights (https://www.eeoc.gov/poster) notice from the Department of Labor.