Medical Assistant/Transition Care
DMC Primary Care
Bedford, NH
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JOB DETAILS
JOB TYPE
Full-time
SKILLS
Acute Care, Behavioral Health, Certified Medical Assistant, Chronic Disease, Clinical Assessment, Community Programs, Disease Prevention and Control, Diversity, Emergency Care, Healthcare, Home Care, Hospital, Medical Assistance, Medical Office, Medications, Needs Assessment, Nursing, Patient Assessment, Patient Care, Primary Care, Quality Assurance, Quality Management, Reconciliation, Social Work, Time Management, Transitional Care
LOCATION
Bedford, NH
POSTED
6 days ago
Are you an experienced Medical Assistant who is ready to join a great team?
DMC Primary Care seeks a Certified Medical Assistant for the full-time role of Transitional Care Specialist (TCS). A TCS is responsible for supporting patients as they transition from inpatient, emergency department, skilled nursing, or acute rehab settings back to the primary care environment. The TCS enhances patient outcomes by coordinating follow-up care, conducting structured post-discharge outreach, ensuring timely communication between care teams, and appropriately addressing clinical or social needs that may impact recovery. This role works closely with providers, nursing staff, care managers, and administrative teams to maintain continuity of care and reduce avoidable readmissions.
Duties Include (but are not limited to):
- Conduct timely post-discharge outreach (phone calls, portal messages, or other approved outreach methods) to assess patient status, confirm discharge instructions, and identify clinical or social concerns.
- Review hospital or rehabilitation discharge summaries, identify required follow-up actions, and route information to the appropriate provider.
- Schedule transitional care management (TCM) visits within required timeframes and support patients in overcoming barriers to attending these appointments.
- Perform structured clinical assessments during outreach calls within CMA scope, including medication reconciliation, symptom check-ins, and identification of red-flag symptoms requiring escalation.
- Collaborate with primary care providers to ensure timely evaluation of complex cases and communicate urgent issues promptly.
- Coordinate with care management, behavioral health, social work, home care, and community resource programs to address identified patient needs.
- Track pending labs, imaging, referrals, or other follow-up items related to transitional care.
- Support quality improvement initiatives related to care transitions, readmission reduction, and chronic disease management.
- Participate in interdisciplinary care meetings and provide updates on transitional care caseloads.
Education and Training: High School Diploma (required)
Experience:
- 3+ years’ experience working in a medical office or healthcare setting
- 2+ years working as a medical assistant
Full time positions at DMC offer:
- Paid time off
- Competitive pay
- Comprehensive health, dental, prescription, and vision benefits
- Company-paid short-term disability, long-term disability and life insurance coverages
- 401k
We are an equal opportunity employer embracing the strength that diversity brings to the workplace. We provide a welcoming and supportive environment for employees of all ethnic backgrounds, cultures, ages, lifestyles and physical abilities.
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About the Company
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