Transitional Care Coach; PRN

Job Details

Job Location:

Corporate - North Olmsted, OH 44070 Position Type:
Per Diem Education Level: License - LPN, RN, or LSW

Reports 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.

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

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.

• 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.

• 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…

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.

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

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

• 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

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

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

• Active, unrestricted Ohio license as:
  • Registered Nurse (RN)
  • Licensed Social Worker (LSW, LISW, LISW-S)
• Stron…