Transitional Care Coordinator (Cleveland, OH)

Location: Cleveland, OH About Us 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, Ohio, Kentucky, Mississippi, 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 ROLE 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 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 QUALIFICATIONS 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; Point Click Care experience preferred 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 (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. EST No evenings No over-night shifts No on-call requirements Seven (7) company-paid holidays annually 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 KEY RESPONSIBILITIES Care Coordination & Transitional Care Management 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 On-Site Clinical Support 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 Communication & Collaboration 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 Documentation & EMR Management 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 Team Support & Leadership 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 Work Environment & Expectations 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 CORE COMPENTACIES Patient-centered care Clinical judgment and escalation Care coordination and continuity Communication and collaboration Documentation accuracy and compliance Relationship-building and teamwork COMPENSATION & BENEFITS 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 Please answer all application questions thoroughly. Thank you for your interest in joining the Ennoble Care team! ❤️ #green Full-time employees qualify for the following 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 All employees qualify for these benefits: 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.