Transitional Care Coach (PRN)

Job DetailsJob Location: Corporate - North Olmsted, OH 44070Position Type: Per DiemEducation Level: License - LPN, RN, or LSWReports to: Care Transitions Supervisor

FLSA Status: Per Diem

The Transitional Care Coach (PRN) position is compensated on a per diem basis, with payment of $45.00 for each completed telephonic assessment and $80.00 for each completed home-visit assessment.

Dedicate yourself to an Organization and Mission you can be proud of by joining the Western Reserve Area Agency on Aging!

Our Mission:

We provide choices for people to live independently in the place they want to call home.

About Us:

Western Reserve Area Agency on Aging (WRAAA) is a private non-profit corporation, organized and designated by the State of Ohio to be the planning, coordinating and administrative agency for federal and state aging programs in Cuyahoga, Geauga, Lake, Lorain and Medina Counties. It is one of twelve Area Agencies on Aging (AAAs) in the state organized together with local service provider organizations and the Ohio Department of Aging (ODA) to form the state's public aging services network. The network works together to create opportunities for Ohioan's to receive needed home and community services and supports; and to age successfully in their own homes and communities.

Candidates we love…

Self-motivated and compassionate Social Workers (LSWs) and Registered Nurses (RNs) looking to be part of a Best-in Class organization
Team players who are committed to providing superior service to all they serve
Enthusiastic professionals excited to grow with an organization that values dedication, innovation and collaboration.

What our staff loves about us…

A generous six-week PTO program and thirteen paid holidays
A $750.00 investment in professional development through a substantial, annual training funds allotment
A 401K program with company match
Paid parking in a covered parking garage
Medical, Dental, Vision Benefits and so much more…

Position Summary: The Transitional Care Coach provides short-term post-discharge support to individuals transitioning from hospitals, skilled nursing facilities, emergency departments, and observation stays back into the community.

Through assessments, education, medication reconciliation, and care coordination, the Transitional Care Coach helps ensure members understand their care plan, access needed resources and avoid unnecessary hospital readmissions. This role is ideal for professionals who enjoy working independently while making a direct impact on patient outcomes and quality of life.

Job Duties: 

Conduct Comprehensive Care Transition Assessments

Complete in-home or telephonic assessments with recently discharged members, including:

Fall Risk Assessments
Social Determinants of Health (SDOH) Assessments
Medication Reconciliation (if an RN)
Review of discharge instructions and follow-up care needs

Educate and Empower Members

Provide individualized education regarding:

Diagnosis-specific warning signs and red flags
Medication management and adherence
Self-management strategies
Use of Personal Health Records
Appropriate follow-up with healthcare providers

Coordinate Care and Connect Resources

Identify barriers that may impact recovery or independence
Connect members with community-based services and supports
Collaborate with healthcare providers, care managers, and community organizations
Promote continuity of care across healthcare settings

Maintain Accurate Documentation

Document assessments, interventions, and member interactions in accordance with program requirements
Complete documentation within 48 hours of member contact

Support Organizational Excellence

Adhere to all program requirements, clinical standards, organizational policies, and regulatory guidelines
Perform other duties as assigned

Qualifications
· Active, unrestricted Ohio license as:

Registered Nurse (RN)
Licensed Social Worker (LSW, LISW, LISW-S)

Strong assessment, communication, and documentation skills
Comfortable using electronic documentation and health record systems
Reliable transportation and ability to travel throughout:

Cuyahoga County
Geauga County
Lake County
Lorain County
Medina County

        Preferred:

Multistate licensure
Experience in:

Care Transitions
Care Management
Home Health
Population Health
Community-Based Services
Hospital Discharge Planning
Managed Care Programs

If you are interested in joining our team of professionals, please complete the application and upload your resume and a cover letter. We look forward to hearing from you! 

The Agency is committed to providing equal employment and advancement opportunities to all. Employment decisions are made based on each person’s performance, qualifications, and abilities. The Agency does not discriminate in employment opportunities or practices on the basis of race, color, religion, gender, sex, national origin, age, disability status, health status, genetic information or ancestry, protected veteran status, sexual orientation, gender identity or expression, or any other protected characteristic.

Western Reserve Area Agency on Aging’s Equal Employment Opportunity policy covers all aspects of employment practices, including selection, job assignment, compensation, discipline, termination, and access to benefits and training.