Transitional Care Coordinator Jobs
Transitional care coordinator jobs are open across hospitals, health systems, skilled nursing facilities, and home health agencies, from entry-level to senior and care management director roles, with specializations in discharge planning, post-acute coordination, and chronic disease management. Scan the live roles below and apply to whichever ones fit.
Find JobsOverview
Showing 5 of 20+ Transitional Care Coordinator jobs
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 Prince George's County, Maryland. 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 Prince George's County, Maryland. 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 Maryland
- 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 based in the Prince George's County, Maryland area.
- Daytime hours, approximately 8:30 a.m. to 5:00 p.m. EST
- No evenings
- No over-night shifts
- No on-call requirements
- Seven (7) company-paid holidays annually
- Daytime hours, approximately 8:30 a.m. to 5:00 p.m. EST
- 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
- 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
- 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 $19.00 hourly plus quarterly bonus
- 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!❤️
#brown
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.
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 Prince George's County, Maryland. 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 Prince George's County, Maryland. 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 Maryland
- 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 based in the Prince George's County, Maryland area.
- Daytime hours, approximately 8:30 a.m. to 5:00 p.m. EST
- No evenings
- No over-night shifts
- No on-call requirements
- Seven (7) company-paid holidays annually
- Daytime hours, approximately 8:30 a.m. to 5:00 p.m. EST
- 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
- 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
- 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 $19.00 hourly plus quarterly bonus
- 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!❤️
#brown
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.
See All 20 Transitional Care Coordinator Jobs
Find roles that match your experience and apply in just a few clicks.
Find JobsTransitional Care Coordinator Job Market
Who's Hiring
What Employers Look For
The qualifications that appear most often in transitional care coordinator jobs.
- Registered nurse licensure or bachelor's degree in social work or a related health field
- Experience with discharge planning, care transitions, or case management in a clinical setting
- Knowledge of post-acute care options including skilled nursing, home health, and rehabilitation
- Proficiency with electronic health record systems such as Epic or Cerner
- Certification in case management such as CCM or ACM preferred or required
- Strong communication skills for coordinating among patients, families, and multidisciplinary teams
Tips for Your Transitional Care Coordinator Job Search
Tailor your resume to care settings
Highlight the specific care settings you've worked in, whether inpatient, post-acute, or community-based. Recruiters screening transitional care coordinator resumes look for environment fit first, so naming the setting before listing duties sharpens your relevance immediately.
List care coordination certifications prominently
Credentials like ACM, CCM, or CCTM belong near the top of your resume, not buried in a footer. Many applicant tracking systems filter on these before a human reviewer sees your file, so placement matters as much as possession.
Apply early to roles that fit
Migrate Mate lists transitional care coordinator openings from across the United States in one place, so you can find roles that match and apply directly to each listing.
Target postings by care transition model
Search for terms like Care Transitions Intervention, BOOST, or INTERACT in job descriptions. Employers using a named model often want coordinators already familiar with its protocols, and matching that language in your application signals you can contribute from day one.
Prepare patient-outcome examples for interviews
Interviewers for transitional care roles consistently ask for examples of reduced readmissions or improved follow-up rates. Prepare two or three concrete patient-journey stories that show your coordination steps and what changed as a result, without citing proprietary numbers.
Negotiate schedule and caseload alongside pay
Caseload size directly affects your ability to deliver quality transitions. When an offer arrives, ask about average caseload per coordinator and how on-call coverage works. These terms affect burnout and performance reviews as much as compensation does.
Transitional Care Coordinator Jobs: Frequently Asked Questions
Which companies are hiring the most transitional care coordinators?
Ennoble Care, University Hospitals, and DC Champion are hiring the most transitional care coordinators right now, with openings concentrated in Ohio, Texas, and Connecticut, based on current listings on Migrate Mate as of November 2026. Health systems and large regional hospital networks tend to post the highest volume of these roles consistently.
How many transitional care coordinator jobs are remote?
About 0% of transitional care coordinator openings are fully remote or hybrid as of November 2026, with telephonic and telehealth-based follow-up roles accounting for most of the remote share. Coordinator positions embedded in inpatient units or skilled nursing facilities remain predominantly on-site because they require in-person patient assessments and bedside coordination.
How do you become a transitional care coordinator?
Most transitional care coordinators start by earning a nursing degree or a bachelor's degree in social work, then gaining direct patient care experience in a hospital, skilled nursing facility, or home health setting. From there, building familiarity with discharge planning workflows and post-acute referral processes is essential. Earning a case management certification such as the CCM or ACM strengthens your candidacy significantly and is required by many employers.
Can you get a transitional care coordinator job with little experience?
Entry-level transitional care coordinator roles do exist, particularly at community health organizations and smaller regional hospitals that value clinical licensure over years of coordination experience specifically. Emphasizing any discharge planning, care navigation, or patient education work you've done in a nursing or social work role, even informally, helps close the experience gap. Some employers also offer structured onboarding that pairs new coordinators with senior staff during the first months.
What does the transitional care coordinator interview process look like?
Most transitional care coordinator interviews include an initial phone screen with HR, followed by a panel interview with a nursing director, a social work lead, or a care management supervisor. Interviewers typically ask behavioral questions about handling complex discharges, managing patients with limited support systems, and coordinating across care teams under time pressure. Some employers add a scenario-based exercise where you walk through how you'd handle a high-risk readmission case.
Where can I find and apply to transitional care coordinator jobs?
You can find and apply to transitional care coordinator jobs on Migrate Mate, which lists current openings from across the United States in one place. Search for roles that match your care setting experience, licensure, and preferred location, then apply directly to each listing that fits your background and goals.
See All 20 Transitional Care Coordinator Jobs
Find roles that match your experience and apply in just a few clicks.
Find Jobs