Transitions of Care Coordinator Medical Assistant

Job overview

The Transitions of Care Coordinator Medical Assistant role is onsite in Bangor, ME. Compensation is not specified. Penobscot Community Health Center is a federally qualified health center offering an integrated Medical Home Model and a broad range of services. The role helps patients move safely from hospital or facility discharge back to primary care by coordinating timely follow-up, outreach, and access to resources. It connects patients, discharge teams, primary care, and community partners to support continuity of care and identify barriers or urgent needs.

What you'll do

• Review hospital and facility discharges, communicate with discharging teams, and coordinate follow-up appointments. Screen for Transitional Care Management eligibility, document results, and schedule appropriate visits. Contact patients after discharge, document outreach and outcomes, maintain patient cases and EMR records, and route follow-up needs. Identify risks and barriers, collaborate with care teams, and provide clinical services within scope, which may include vital signs, lab draws, vaccines, and point-of-care testing. Participate in hospital rounds and conduct home visits as needed
• connect patients with community resources and referrals.

What we're looking for

Skills & competencies

medical assistant

transitions of care

bangor me

penobscot community health center

care coordination

patient outreach

primary care

emr documentation

tcm

bls certification

monday–friday

8:00 a.m.–4:30 p.m.

Work arrangement

• Weekend coverage required

Benefits & perks

• Competitive compensation and generous benefits are stated
• specific benefits are not detailed in the posting.

Why this role

Full-time Monday–Friday, 8:00 a.m.–4:30 p.m. Requires an MA, CMA, RMA, or CCMA certification, three years of primary healthcare experience, and current healthcare provider Basic Life Support certification or completion within two weeks of hire. Maine healthcare worker immunization requirements apply.

About the employer

Penobscot Community Health Center is hiring for this role. Industry: All Other Outpatient Care Centers. Sector: 62.